MEDICARE: SANJEEV THAMMAN MHS,OTR

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	225X00000X	Occupational Therapist	5201002120	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5201002120	OTHER	MI	STATE OF MICHIGAN

General Provider Information

NPI Number	:	1558547570
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SANJEEV THAMMAN MHS,OTR

Provider Business Mailing Address
First Line	:	1994 TALL PINES DR SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49546-7922
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1994 TALL PINES DR SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49546-7922
Country	:	US
Telephone Number	:	616-856-0102
Fax Number	:

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

Provider Enumeration Date	:	01/21/2008
Last Update Date	:	11/12/2014

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