MEDICARE: THUNDER BAY THERAPY & SPORTS MEDICINE, PLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR0400X	Rehabilitation Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	30720	OTHER	MI	BLUE CROSS &BS

General Provider Information

NPI Number	:	1386699031
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THUNDER BAY THERAPY & SPORTS MEDICINE, PLC

Provider Business Mailing Address
First Line	:	348 LONG RAPIDS PLZ
Second Line	:
City	:	ALPENA
State	:	MI
Zip	:	49707-1374
Country	:	US
Telephone Number	:	989-358-8086
Fax Number	:	989-354-2253

Provider Business Practice Location Address
First Line	:	348 LONG RAPIDS PLZ
Second Line	:
City	:	ALPENA
State	:	MI
Zip	:	49707-1374
Country	:	US
Telephone Number	:	989-358-8086
Fax Number	:	989-354-2253

Authorized Official
Title or Position	:	CLINIC ADMINISTRATOR
Name	:	MRS. TERESA LYNN DUNCAN
Credential	:	PHYSCIAL THERAPIST
Telephone Number	:	989-358-8086

Provider Enumeration Date	:	05/23/2006
Last Update Date	:	12/04/2007

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