MEDICARE: MRS. BRENDA ANNE ROSS 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	5501013896	MI

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	236836	OTHER	MI	MEDICARE PROVIDER

General Provider Information

NPI Number	:	1902052574
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. BRENDA ANNE ROSS MPT

Provider Business Mailing Address
First Line	:	29100 GATEWAY BLVD
Second Line	:	SUITE 400
City	:	FLAT ROCK
State	:	MI
Zip	:	48134-2764
Country	:	US
Telephone Number	:	734-379-7900
Fax Number	:

Provider Business Practice Location Address
First Line	:	29100 GATEWAY BLVD
Second Line	:	SUITE 400
City	:	FLAT ROCK
State	:	MI
Zip	:	48134-2764
Country	:	US
Telephone Number	:	734-379-7900
Fax Number	:

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

Provider Enumeration Date	:	08/14/2008
Last Update Date	:	08/14/2008

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