Basic Information
| Provider Information | |||||||||
| NPI: | 1164903688 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FUNYAK | ||||||||
| FirstName: | MICHAEL | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 E MEDICAL CENTER DR | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481095000 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 39901 TRADITIONS DR | ||||||||
| Address2: | |||||||||
| City: | NORTHVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481689493 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483054400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2018 | ||||||||
| LastUpdateDate: | 08/23/2018 | ||||||||
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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 | 5501018704 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 30106197 | 01 | PA | DRIVER'S LICENSE NUMBER | OTHER |