Healthcare Provider Details

I. General information

NPI: 1003817909
Provider Name (Legal Business Name): MICHIGAN SPINE & ORTHOPEDIC REHAB INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 05/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4918 W CLARK RD STE 102
YPSILANTI MI
48197-1142
US

IV. Provider business mailing address

4918 W CLARK RD STE 102
YPSILANTI MI
48197-1142
US

V. Phone/Fax

Practice location:
  • Phone: 734-572-9800
  • Fax: 734-572-0762
Mailing address:
  • Phone: 734-572-9800
  • Fax: 734-572-0762

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number5501003609
License Number StateMI

VIII. Authorized Official

Name: BARBARA J JOHNSON
Title or Position: PRESIDENT
Credential: MS, PT
Phone: 734-572-9800