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General NPI Number Information
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NPI Number | 1861930109
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Entity Type | Organization
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Legal Business Name | EXCEL PHYSICAL MEDICINE AND REHABILITATION PC
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Dates
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Enumeration Date | 02/07/2017
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Last Update Date | 09/27/2017
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Provider Practice Location Address
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Address Line | 6089 W MAPLE RD SUITE 250A
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City | WEST BLOOMFIELD
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State | MI
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Zip | 48322-2286
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Country | US
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Telephone | 248-855-4400
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Fax | 248-855-4414
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Provider Business Mailing Address
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Address Line | 7071 ORCHARD LAKE RD SUITE 333
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City | WEST BLOOMFIELD
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State | MI
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Zip | 48322-3613
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Country | US
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Telephone | 248-626-0470
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Fax | 248-626-0221
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Authorized Official
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Title or Position | CEO
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Name | DR. AUGUSTUS PETER EVANGELISTA
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Credential | M.D.
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Telephone | 248-855-4400
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2081P2900X
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Taxonomy Name | Pain Medicine (Physical Medicine & Rehabilitation) Physician
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License Number | 4301108922
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number |
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License Number State | MI
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Taxonomy #3
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number | 4301108922
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License Number State | MI
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