=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093532749
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KARL MAGNUSON
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/24/2024
-----------------------------------------------------
Last Update Date | 09/24/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6167 WHITE LAKE RD STE 1
-----------------------------------------------------
City | CLARKSTON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48346-2070
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-620-4260
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2000 WESTINGHOUSE DR STE 200
-----------------------------------------------------
City | CRANBERRY TWP
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16066-5238
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-343-4060
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 5501303560
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------