Provider Demographics
NPI:1659671030
Name:MCDANIEL, MARK ANDREW (PT,DPT,CSCS)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ANDREW
Last Name:MCDANIEL
Suffix:
Gender:M
Credentials:PT,DPT,CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2251 N SQUIRREL RD
Mailing Address - Street 2:STE 301
Mailing Address - City:AUBURN HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48326-4600
Mailing Address - Country:US
Mailing Address - Phone:248-681-4206
Mailing Address - Fax:248-681-5798
Practice Address - Street 1:2251 N SQUIRREL RD
Practice Address - Street 2:STE 301
Practice Address - City:AUBURN HILLS
Practice Address - State:MI
Practice Address - Zip Code:48326-4600
Practice Address - Country:US
Practice Address - Phone:248-681-4206
Practice Address - Fax:248-681-5798
Is Sole Proprietor?:No
Enumeration Date:2010-11-01
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501015417225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M79640009Medicare PIN