MEDICARE: ORTHOSPORT PHYSICAL THERAPY AND ATHLETIC REHABILITATION INC.

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	2251X0800X	Orthopedic Physical Therapist	5501008449	MI

General Provider Information

NPI Number	:	1710995246
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ORTHOSPORT PHYSICAL THERAPY AND ATHLETIC REHABILITATION INC.

Provider Business Mailing Address
First Line	:	2230 E MITCHELL RD
Second Line	:	SUITE B
City	:	PETOSKEY
State	:	MI
Zip	:	49770-6601
Country	:	US
Telephone Number	:	231-348-1011
Fax Number	:	231-348-6998

Provider Business Practice Location Address
First Line	:	2230 E MITCHELL RD
Second Line	:	SUITE B
City	:	PETOSKEY
State	:	MI
Zip	:	49770-6601
Country	:	US
Telephone Number	:	231-348-1011
Fax Number	:	231-348-6998

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	MR. ALAN AUGUST BUDNICK
Credential	:	MPT,OCS
Telephone Number	:	231-348-1011

Provider Enumeration Date	:	08/03/2006
Last Update Date	:	08/22/2020

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