Healthcare Provider Details

I. General information

NPI: 1578702502
Provider Name (Legal Business Name): RAJESH KUPPUSAMY PHYSICAL THERAPIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2009
Last Update Date: 02/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11293 TERRACE VIEW DR
WHITMORE LAKE MI
48189-9126
US

IV. Provider business mailing address

11293 TERRACE VIEW DR
WHITMORE LAKE MI
48189-9126
US

V. Phone/Fax

Practice location:
  • Phone: 810-623-9535
  • Fax: 810-231-1198
Mailing address:
  • Phone: 810-623-9535
  • Fax: 810-231-1198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number5501008776
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: