MEDICARE: MR. MARC WILLIAM HINZE M.P.T.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	5501011803	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	650C901900	OTHER	MI	BCBS
2	155812	OTHER		GREAT LAKES HLTH PLAN
3	7173604	OTHER		AETNA PIN

General Provider Information

NPI Number	:	1104866573
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MARC WILLIAM HINZE M.P.T.

Provider Business Mailing Address
First Line	:	4613 W MAIN ST
Second Line	:	SUITE C
City	:	KALAMAZOO
State	:	MI
Zip	:	49006-2645
Country	:	US
Telephone Number	:	269-488-8360
Fax Number	:	269-488-8359

Provider Business Practice Location Address
First Line	:	4613 W MAIN ST
Second Line	:	SUITE C
City	:	KALAMAZOO
State	:	MI
Zip	:	49006-2645
Country	:	US
Telephone Number	:	269-488-8360
Fax Number	:	269-488-8359

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/07/2006
Last Update Date	:	01/07/2011

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