MEDICARE: PRYDE PHYSICAL THERAPY PLLC

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

General Provider Information

NPI Number	:	1912503830
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRYDE PHYSICAL THERAPY PLLC

Provider Business Mailing Address
First Line	:	5536 RESEARCH DR STE 186
Second Line	:
City	:	CANTON
State	:	MI
Zip	:	48188-2978
Country	:	US
Telephone Number	:	734-895-1901
Fax Number	:	855-794-1008

Provider Business Practice Location Address
First Line	:	5536 RESEARCH DR
Second Line	:
City	:	CANTON
State	:	MI
Zip	:	48188-2261
Country	:	US
Telephone Number	:	734-895-1901
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	IVAN ANKWATSA
Credential	:
Telephone Number	:	734-895-1901

Provider Enumeration Date	:	12/07/2020
Last Update Date	:	07/01/2026

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