Basic Information
| Provider Information | |||||||||
| NPI: | 1619392354 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MICHIGAN REHABILITATION SPECIALISTS OF FOWLERVILLE, LLC | ||||||||
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| OtherOrganizationName: | ATI PHYSICAL THERAPY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 790 REMINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604404909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302962223 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1949 W MAPLE RD | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480847109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2482685497 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2014 | ||||||||
| LastUpdateDate: | 05/03/2018 | ||||||||
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| AuthorizedOfficialLastName: | MCGIVERN | ||||||||
| AuthorizedOfficialFirstName: | LYNN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF COMPLIANCE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6302962222 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CCO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | MI | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225X00000X | MI | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 332B00000X | MI | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.