Provider Demographics
NPI:1750597324
Name:PROFESSIONAL PT AND REHAB PC
Entity type:Organization
Organization Name:PROFESSIONAL PT AND REHAB PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SMITA
Authorized Official - Middle Name:
Authorized Official - Last Name:AHLUWALIA
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:248-582-9907
Mailing Address - Street 1:31150 HOOVER RD
Mailing Address - Street 2:STE C
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-7618
Mailing Address - Country:US
Mailing Address - Phone:586-268-1929
Mailing Address - Fax:586-268-1933
Practice Address - Street 1:31150 HOOVER RD
Practice Address - Street 2:STE C
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-7618
Practice Address - Country:US
Practice Address - Phone:586-268-1929
Practice Address - Fax:586-268-1933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2009-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501005394225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104696147Medicaid
MI650F339030OtherBCBSM
MI125076OtherGREAT LAKES HEALTH PLAN
MI650019090OtherRAILROAD MEDICARE
MIP106004OtherBLUECARE NETWORK
MI104696147Medicaid
MI650019090OtherRAILROAD MEDICARE