Healthcare Provider Details

I. General information

NPI: 1861930109
Provider Name (Legal Business Name): EXCEL PHYSICAL MEDICINE AND REHABILITATION PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2017
Last Update Date: 09/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6089 W MAPLE RD SUITE 250A
WEST BLOOMFIELD MI
48322-2286
US

IV. Provider business mailing address

7071 ORCHARD LAKE RD SUITE 333
WEST BLOOMFIELD MI
48322-3613
US

V. Phone/Fax

Practice location:
  • Phone: 248-855-4400
  • Fax: 248-855-4414
Mailing address:
  • Phone: 248-626-0470
  • Fax: 248-626-0221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number4301108922
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number4301108922
License Number StateMI

VIII. Authorized Official

Name: DR. AUGUSTUS PETER EVANGELISTA
Title or Position: CEO
Credential: M.D.
Phone: 248-855-4400