=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417346032
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE MEDICAL TEAM
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/20/2015
-----------------------------------------------------
Last Update Date | 01/20/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17197 N LAUREL PARK DR STE 555
-----------------------------------------------------
City | LIVONIA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48152-2686
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-779-9700
-----------------------------------------------------
Fax | 734-779-7999
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17622 VALADE ST
-----------------------------------------------------
City | RIVERVIEW
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48193-4721
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-283-2742
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CERTIFIED OCCUPATIONAL THERAPY ASST
-----------------------------------------------------
Name | MR. MICHAEL A. HILTZ
-----------------------------------------------------
Credential | COTAL
-----------------------------------------------------
Telephone | 734-283-2742
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | 5202007380
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------