Basic Information
| Provider Information | |||||||||
| NPI: | 1154402329 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHEPPARD | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | JOHN | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 33900 HARPER AVE | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | CLINTON TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480354258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5864169100 | ||||||||
| FaxNumber: | 5864169103 | ||||||||
| Practice Location | |||||||||
| Address1: | 23655 NOVI RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | NOVI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483755442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2482773440 | ||||||||
| FaxNumber: | 2482773441 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 11/29/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 5501009609 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 650F333630 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER |