Healthcare Provider Details

I. General information

NPI: 1215240502
Provider Name (Legal Business Name): MICHIGAN REHABILITATION PHYSICIANS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2010
Last Update Date: 04/24/2020
Certification Date: 04/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17187 SCHAEFER HWY
DETROIT MI
48235-4132
US

IV. Provider business mailing address

PO BOX 93
FRASER MI
48026-0093
US

V. Phone/Fax

Practice location:
  • Phone: 313-367-2767
  • Fax: 313-367-2818
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number4301086814
License Number StateMI

VIII. Authorized Official

Name: DR. PETER HANNA GUMMA
Title or Position: OWNER
Credential: MD
Phone: 313-367-2767