=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336298421
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UPPER PENINSULA SPORTS MEDICINE & THERAPY CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/09/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1414 W FAIR AVE SUITE 101
-----------------------------------------------------
City | MARQUETTE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49855-2675
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 906-228-2595
-----------------------------------------------------
Fax | 906-228-3313
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1414 W FAIR AVE SUITE 101
-----------------------------------------------------
City | MARQUETTE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49855-2675
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 906-228-2595
-----------------------------------------------------
Fax | 906-228-3313
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICAL THERAPIST
-----------------------------------------------------
Name | MR. JOHN MICHAEL PHILLIPS
-----------------------------------------------------
Credential | P.T.
-----------------------------------------------------
Telephone | 906-228-2595
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------