MEDICARE: EDSEL D OBRA PT

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	5501011778	MI

General Provider Information

NPI Number	:	1609341619
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EDSEL D OBRA PT

Provider Business Mailing Address
First Line	:	37764 IRENE DR
Second Line	:
City	:	STERLING HEIGHTS
State	:	MI
Zip	:	48312-1934
Country	:	US
Telephone Number	:	586-722-4735
Fax Number	:	586-264-8525

Provider Business Practice Location Address
First Line	:	37764 IRENE DR
Second Line	:
City	:	STERLING HEIGHTS
State	:	MI
Zip	:	48312-1934
Country	:	US
Telephone Number	:	586-722-4735
Fax Number	:	586-264-8525

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

Provider Enumeration Date	:	10/05/2018
Last Update Date	:	10/05/2018

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