Healthcare Provider Details

I. General information

NPI: 1861690695
Provider Name (Legal Business Name): AVNISH MAHAJAN MPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10501 TELEGRAPH RD
TAYLOR MI
48180-3375
US

IV. Provider business mailing address

37872 BAYWOOD DR
FARMINGTON HILLS MI
48335-3610
US

V. Phone/Fax

Practice location:
  • Phone: 313-299-0000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251C2600X
TaxonomyCardiopulmonary Physical Therapist
License Number5501009545
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: