Basic Information
Provider Information | |||||||||
NPI: | 1831334580 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STOCKMAN | ||||||||
FirstName: | BRIAN | ||||||||
MiddleName: | L. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MPT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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: | 1081 BROAD RIPPLE AVE | ||||||||
Address2: |   | ||||||||
City: | INDIANAPOLIS | ||||||||
State: | IN | ||||||||
PostalCode: | 462202034 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3178080350 | ||||||||
FaxNumber: | 3178080349 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/10/2008 | ||||||||
LastUpdateDate: | 05/31/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 05009690A | IN | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 156546 | 01 | IN | GROUP MEDICARE | OTHER | 200930400A | 05 | IN |   | MEDICAID | 100257920 | 01 | IN | GROUP MEDICAID | OTHER |