MEDICARE: KASHIF YAQUB RPT

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	KY012346	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	KY012346	OTHER	MI	STATE LICENSE

General Provider Information

NPI Number	:	1932304219
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KASHIF YAQUB RPT

Provider Business Mailing Address
First Line	:	22260 GREEN HILL RD # 5
Second Line	:
City	:	FARMINGTON HILLS
State	:	MI
Zip	:	48335-4374
Country	:	US
Telephone Number	:	248-682-6627
Fax Number	:	248-889-7534

Provider Business Practice Location Address
First Line	:	1396 SCOTT LAKE RD
Second Line	:
City	:	WATERFORD
State	:	MI
Zip	:	48328-1578
Country	:	US
Telephone Number	:	248-682-6627
Fax Number	:

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

Provider Enumeration Date	:	06/18/2007
Last Update Date	:	07/08/2007

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