Provider Demographics
| NPI: | 1982674040 |
|---|---|
| Name: | GREAT LAKES ORTHOPEDIC PHYSICAL THERAPY, INC. |
| Entity type: | Organization |
| Organization Name: | GREAT LAKES ORTHOPEDIC PHYSICAL THERAPY, INC. |
| Other - Org Name: | <UNAVAIL> |
| Other - Org Type: | |
| Authorized Official - Title/Position: | PRESIDENT |
| Authorized Official - Prefix: | DR |
| Authorized Official - First Name: | PIOTR |
| Authorized Official - Middle Name: | |
| Authorized Official - Last Name: | KLUBA |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | PT |
| Authorized Official - Phone: | 586-977-5700 |
| Mailing Address - Street 1: | 38300 VAN DYKE AVE |
| Mailing Address - Street 2: | SUITE 101 |
| Mailing Address - City: | STERLING HEIGHTS |
| Mailing Address - State: | MI |
| Mailing Address - Zip Code: | 48312-1123 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 586-977-5700 |
| Mailing Address - Fax: | 586-977-5704 |
| Practice Address - Street 1: | 38300 VAN DYKE AVE |
| Practice Address - Street 2: | SUITE 101 |
| Practice Address - City: | STERLING HEIGHTS |
| Practice Address - State: | MI |
| Practice Address - Zip Code: | 48312-1123 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 586-977-5700 |
| Practice Address - Fax: | 586-977-5704 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2006-01-23 |
| Last Update Date: | 2013-02-15 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 2251X0800X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic | Group - Multi-Specialty |
| No | 104100000X | Behavioral Health & Social Service Providers | Social Worker | Group - Multi-Specialty | |
| No | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Group - Multi-Specialty | |
| No | 2251E1200X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Ergonomics | Group - Multi-Specialty |
| No | 2251G0304X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Geriatrics | Group - Multi-Specialty |
| No | 2251H1200X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Hand | Group - Multi-Specialty |
| No | 2251N0400X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Neurology | Group - Multi-Specialty |
| No | 2251P0200X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Pediatrics | Group - Multi-Specialty |
| No | 2251S0007X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Sports | Group - Multi-Specialty |
| No | 225X00000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Group - Multi-Specialty | |
| No | 235Z00000X | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| MI | 4687504 | Medicaid | |
| MI | 4687504 | Medicaid | |
| MI | 236631 | Medicare Oscar/Certification |
