Basic Information
| Provider Information | |||||||||
| NPI: | 1609903194 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HEARTLAND REHABILITATION SERVICES OF MICHIGAN, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HEARTLAND REHABILITATION SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10086 | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436991417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192525500 | ||||||||
| FaxNumber: | 8773859446 | ||||||||
| Practice Location | |||||||||
| Address1: | 7577 SECOR RD | ||||||||
| Address2: | |||||||||
| City: | LAMBERTVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481449624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7348566737 | ||||||||
| FaxNumber: | 7348566741 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2007 | ||||||||
| LastUpdateDate: | 09/12/2017 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ALLEN | ||||||||
| AuthorizedOfficialFirstName: | MARTIN | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT - REIMBURSEMENTS | ||||||||
| AuthorizedOfficialTelephone: | 4192525734 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 4691580 | 05 | MI | MEDICAID |