Healthcare Provider Details

I. General information

NPI: 1912913070
Provider Name (Legal Business Name): MICHAEL DAVID MCGOUGH DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45551 MOUND RD
SHELBY TWP MI
48317
US

IV. Provider business mailing address

42615 GARFIELD ROAD
CLINTON TOWNSHIP MI
48038
US

V. Phone/Fax

Practice location:
  • Phone: 586-323-9224
  • Fax: 989-944-9226
Mailing address:
  • Phone: 586-412-2846
  • Fax: 586-412-7087

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501012554
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: