Provider Demographics
NPI:1053583013
Name:SURYAVANSHI, MUKESH KUMAR (PT)
Entity type:Individual
Prefix:MR
First Name:MUKESH
Middle Name:KUMAR
Last Name:SURYAVANSHI
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 W NEPESSING ST STE A
Mailing Address - Street 2:
Mailing Address - City:LAPEER
Mailing Address - State:MI
Mailing Address - Zip Code:48446-2150
Mailing Address - Country:US
Mailing Address - Phone:810-245-9400
Mailing Address - Fax:810-245-9080
Practice Address - Street 1:404 W NEPESSING ST STE A
Practice Address - Street 2:
Practice Address - City:LAPEER
Practice Address - State:MI
Practice Address - Zip Code:48446-2150
Practice Address - Country:US
Practice Address - Phone:810-245-9400
Practice Address - Fax:810-245-9080
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-31
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501005880225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP21730001Medicare PIN