MEDICARE: MR. PROMODH JOSEPH PT

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	5501007640	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	650E900140	OTHER	MI	BCBS PROVIDERNUMBER

General Provider Information

NPI Number	:	1598783854
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. PROMODH JOSEPH PT

Provider Business Mailing Address
First Line	:	7762 NORTH FEDERAL RD
Second Line	:	P.O.BOX 256
City	:	HOWARD CITY
State	:	MI
Zip	:	49329
Country	:	US
Telephone Number	:	231-937-8485
Fax Number	:	231-937-9836

Provider Business Practice Location Address
First Line	:	7762 NORTH FEDERAL RD
Second Line	:
City	:	HOWARD CITY
State	:	MI
Zip	:	49329
Country	:	US
Telephone Number	:	231-937-8485
Fax Number	:	231-937-9836

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

Provider Enumeration Date	:	07/17/2006
Last Update Date	:	07/08/2007

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Directions to “ MR. PROMODH JOSEPH PT” Practice Location

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