Healthcare Provider Details

I. General information

NPI: 1225620214
Provider Name (Legal Business Name): NATHAN RONALD CHAMPOUX
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2021
Last Update Date: 02/10/2021
Certification Date: 02/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 E MEDICAL CENTER DR
ANN ARBOR MI
48109-5000
US

IV. Provider business mailing address

1500 E MEDICAL CENTER DR
ANN ARBOR MI
48109-5000
US

V. Phone/Fax

Practice location:
  • Phone: 734-936-7070
  • Fax:
Mailing address:
  • Phone: 734-936-7070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501019900
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: