Provider Demographics
NPI:1447441076
Name:SAMUEL, MOBY (PT)
Entity type:Individual
Prefix:
First Name:MOBY
Middle Name:
Last Name:SAMUEL
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 1:43740 GARFIELD RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1122
Mailing Address - Country:US
Mailing Address - Phone:586-228-0270
Mailing Address - Fax:586-228-9019
Practice Address - Street 1:43740 GARFIELD RD
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-1122
Practice Address - Country:US
Practice Address - Phone:586-228-0270
Practice Address - Fax:586-228-9019
Is Sole Proprietor?:No
Enumeration Date:2007-08-08
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501012326225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP15790004Medicare PIN