Healthcare Provider Details

I. General information

NPI: 1508101544
Provider Name (Legal Business Name): MARKUS M MIJNSBERGEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/03/2012
Last Update Date: 12/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 S MAIN ST
PLYMOUTH MI
48170-1711
US

IV. Provider business mailing address

650 S MAIN ST
PLYMOUTH MI
48170-1711
US

V. Phone/Fax

Practice location:
  • Phone: 734-455-8370
  • Fax:
Mailing address:
  • Phone: 734-455-8370
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number5501003840
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: