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NPI Code Detail

MEDICARE: MR. SHAWN MICHAEL BLACK M.S., P.T.

MEDICARE: MR. SHAWN MICHAEL BLACK M.S., P.T.
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
1208100000XPhysical Medicine & Rehabilitation Physician5501011285MI
2225100000XPhysical Therapist5501011285MI

General Provider Information

NPI Number : 1679603575
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. SHAWN MICHAEL BLACK M.S., P.T.
Provider Business Mailing Address
First Line : 1189 GONDER RD
Second Line :
City : INTERLOCHEN
State : MI
Zip : 49643-9705
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 701 US HIGHWAY 31 S
Second Line :
City : TRAVERSE CITY
State : MI
Zip : 49685-8016
Country : US
Telephone Number : 800-406-5143
Fax Number : 231-995-9302
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/07/2007
Last Update Date : 05/07/2025

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