Provider Demographics
NPI:1295741619
Name:MICHIGAN PHYSICAL MEDICINE AND REHABILITATION, P.C.
Entity type:Organization
Organization Name:MICHIGAN PHYSICAL MEDICINE AND REHABILITATION, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:L
Authorized Official - Last Name:BRADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:586-468-3900
Mailing Address - Street 1:20950 HARRINGTON ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48036-1923
Mailing Address - Country:US
Mailing Address - Phone:586-468-3900
Mailing Address - Fax:586-468-9811
Practice Address - Street 1:20950 HARRINGTON ST
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48036-1923
Practice Address - Country:US
Practice Address - Phone:586-468-3900
Practice Address - Fax:586-468-9811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101012404208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI250E020580OtherBCBS PIN
MI495487811Medicaid
MI0P37660Medicare PIN
MI250E020580OtherBCBS PIN