Provider Demographics
NPI:1780878561
Name:ANTHONY, JIMMIE JAMES
Entity type:Individual
Prefix:
First Name:JIMMIE
Middle Name:JAMES
Last Name:ANTHONY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 E LAKETON AVE
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49442-5507
Mailing Address - Country:US
Mailing Address - Phone:231-728-4102
Mailing Address - Fax:231-722-0800
Practice Address - Street 1:137 E LAKETON AVE
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49442-5507
Practice Address - Country:US
Practice Address - Phone:231-728-4102
Practice Address - Fax:231-722-0800
Is Sole Proprietor?:No
Enumeration Date:2007-09-05
Last Update Date:2007-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501007594225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN23350001Medicare PIN