Provider Demographics
NPI:1295810851
Name:TEKUMULLA, HARGOPAL (PT)
Entity type:Individual
Prefix:MR
First Name:HARGOPAL
Middle Name:
Last Name:TEKUMULLA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1702 WATER ST
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-4136
Mailing Address - Country:US
Mailing Address - Phone:810-966-9102
Mailing Address - Fax:810-966-9104
Practice Address - Street 1:1702 WATER ST
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-4136
Practice Address - Country:US
Practice Address - Phone:810-966-9102
Practice Address - Fax:810-966-9104
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501008202225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI48102OtherHEALTH PLAN OF MICHIGAN
MI4863011Medicaid
MI0G41113OtherBLUE CARE NETWORK, MICHIGAN
MI650G411130OtherBCBS OF MICHIGAN
MI164232OtherGREAT LAKES HEALTH PLAN
MIOP28290Medicare PIN
MI650G411130OtherBCBS OF MICHIGAN