Provider Demographics
NPI:1700960051
Name:MICHIGAN PHYSICAL THERAPY ASSOCIATES
Entity Type:Organization
Organization Name:MICHIGAN PHYSICAL THERAPY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:SUMIT
Authorized Official - Middle Name:
Authorized Official - Last Name:GUPTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-424-3201
Mailing Address - Street 1:5409 GATEWAY CTR
Mailing Address - Street 2:STE B
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48507-3992
Mailing Address - Country:US
Mailing Address - Phone:810-424-3201
Mailing Address - Fax:810-424-3202
Practice Address - Street 1:5409 GATEWAY CTR
Practice Address - Street 2:STE B
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-3992
Practice Address - Country:US
Practice Address - Phone:810-424-3201
Practice Address - Fax:810-424-3202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2014-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501005488225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIDG1947OtherMCR RR
MI5804020001Medicare NSC
MIDG1947OtherMCR RR