MEDICARE: MR. DEREK J BABIN MPT

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	5501009775	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	155812	OTHER		GREAT LAKES HLTH PLN
2	7173604	OTHER		AETNA GRP PIN

General Provider Information

NPI Number	:	1972546372
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DEREK J BABIN MPT

Provider Business Mailing Address
First Line	:	4613 W MAIN ST
Second Line	:	SUITE C
City	:	KALAMAZOO
State	:	MI
Zip	:	49006-2645
Country	:	US
Telephone Number	:	269-488-8360
Fax Number	:	269-488-8359

Provider Business Practice Location Address
First Line	:	4613 W MAIN ST
Second Line	:	SUITE C
City	:	KALAMAZOO
State	:	MI
Zip	:	49006-2645
Country	:	US
Telephone Number	:	269-488-8360
Fax Number	:	269-488-8359

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

Provider Enumeration Date	:	06/14/2006
Last Update Date	:	09/09/2009

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