Healthcare Provider Details

I. General information

NPI: 1538377999
Provider Name (Legal Business Name): JONY JOSEPH PUTHENEDATHUMADATHIL RPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28301 FRANKLIN RD SUITE A325
SOUTHFIELD MI
48034-1672
US

IV. Provider business mailing address

1467 MOMENTUM PL PO BOX 231467
CHICAGO IL
60689-5314
US

V. Phone/Fax

Practice location:
  • Phone: 248-203-6636
  • Fax: 734-266-7100
Mailing address:
  • Phone: 800-827-3797
  • Fax: 248-553-2108

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501012939
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: