Basic Information
| Provider Information | |||||||||
| NPI: | 1730230053 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY OF MICHIGAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8736 BARRINGTON DR | ||||||||
| Address2: | |||||||||
| City: | SUPERIOR TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481983289 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 8736 BARRINGTON DR | ||||||||
| Address2: | |||||||||
| City: | SUPERIOR TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481983289 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7349307400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | ANDERSON | ||||||||
| AuthorizedOfficialFirstName: | RYAN | ||||||||
| AuthorizedOfficialMiddleName: | JAMES | ||||||||
| AuthorizedOfficialTitleorPosition: | CERTIFIED ATHLETIC TRAINER | ||||||||
| AuthorizedOfficialTelephone: | 7349307400 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | ATC, CSCS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.