Healthcare Provider Details

I. General information

NPI: 1033610886
Provider Name (Legal Business Name): DEREK CHAN PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2018
Last Update Date: 04/06/2021
Certification Date: 04/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6525 2ND AVE
DETROIT MI
48202-3006
US

IV. Provider business mailing address

25146 HUNTER LN
FLAT ROCK MI
48134-1843
US

V. Phone/Fax

Practice location:
  • Phone: 313-972-4140
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number5501009637
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number5501009637
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: