Healthcare Provider Details

I. General information

NPI: 1912962127
Provider Name (Legal Business Name): JEFFREY R SIRABIAN PT MHS OCS CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9368 LILLEY ROAD
PLYMOUTH MI
48170
US

IV. Provider business mailing address

9368 LILLEY ROAD
PLYMOUTH MI
48170
US

V. Phone/Fax

Practice location:
  • Phone: 734-416-3900
  • Fax: 734-416-3903
Mailing address:
  • Phone: 734-416-3900
  • Fax: 734-416-3903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501004054
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: