Provider Demographics
NPI:1669588018
Name:BHARGAVA, AJAY KUMAR (PT)
Entity type:Individual
Prefix:
First Name:AJAY
Middle Name:KUMAR
Last Name:BHARGAVA
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 1:3530 E HIAWATHA DR
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-4041
Mailing Address - Country:US
Mailing Address - Phone:517-372-2700
Mailing Address - Fax:517-349-4298
Practice Address - Street 1:1601 E MICHIGAN AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-2894
Practice Address - Country:US
Practice Address - Phone:517-349-4268
Practice Address - Fax:517-349-4298
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501005343225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI650C312140OtherBCBS PROVIDER ID
MI104552480Medicaid
MI650C312140OtherBCBS PROVIDER ID
MI0N77760Medicare ID - Type UnspecifiedPROVIDER ID