Healthcare Provider Details

I. General information

NPI: 1902924715
Provider Name (Legal Business Name): MICHAEL WILLIAMS PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 02/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 RONALD REAGAN PKWY MG100
AVON IN
46123-7085
US

IV. Provider business mailing address

1220 CONSTITUTION DR
INDIANAPOLIS IN
46234-9779
US

V. Phone/Fax

Practice location:
  • Phone: 317-217-3075
  • Fax:
Mailing address:
  • Phone: 317-271-5635
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number05006224A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: