MEDICARE: VINOTH PERIYASAMY MPT

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	5501013741	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1861721656
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VINOTH PERIYASAMY MPT

Provider Business Mailing Address
First Line	:	2445 TAVISTOCK CT
Second Line	:
City	:	STERLING HEIGHTS
State	:	MI
Zip	:	48310-7109
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2445 TAVISTOCK CT
Second Line	:
City	:	STERLING HEIGHTS
State	:	MI
Zip	:	48310-7109
Country	:	US
Telephone Number	:	248-764-0700
Fax Number	:

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

Provider Enumeration Date	:	12/08/2009
Last Update Date	:	12/08/2009

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