MEDICARE: MRS. SHANNON MICHAEL MPT.

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	225100000X	Physical Therapist	5501012116	MI

General Provider Information

NPI Number	:	1518978675
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SHANNON MICHAEL MPT.

Provider Business Mailing Address
First Line	:	790 REMINGTON BLVD
Second Line	:
City	:	BOLINGBROOK
State	:	IL
Zip	:	60440-4909
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5832 NORTH LAPEER RD
Second Line	:	FULL CIRCLE PHYSICAL THERAPY SUITE A
City	:	NORTH BRANCH
State	:	MI
Zip	:	48461
Country	:	US
Telephone Number	:	810-793-5282
Fax Number	:	810-793-5281

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/11/2006
Last Update Date	:	09/02/2015

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