=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639694383
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ORTHOPEDIC SPINE & SPORTS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/03/2017
-----------------------------------------------------
Last Update Date | 08/03/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 480 E 2ND ST
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48307-2006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-340-1100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2558 N SQUIRREL RD
-----------------------------------------------------
City | AUBURN HILLS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48326-2383
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-340-1100
-----------------------------------------------------
Fax | 248-340-1101
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | SHANNON BRANNING
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 248-340-1100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------