Healthcare Provider Details

I. General information

NPI: 1962087262
Provider Name (Legal Business Name): GERALD LEE PHILO JR. PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2021
Last Update Date: 03/24/2021
Certification Date: 03/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5500 AUTO CLUB DR STE 150
DEARBORN MI
48126-2779
US

IV. Provider business mailing address

5500 AUTO CLUB DR STE 150
DEARBORN MI
48126-2779
US

V. Phone/Fax

Practice location:
  • Phone: 313-982-8266
  • Fax: 313-982-8098
Mailing address:
  • Phone: 313-982-8266
  • Fax: 313-982-8098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number5502000079
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: