Provider Demographics
NPI:1902969389
Name:AMIN, MITAL RAJIV (MPT)
Entity Type:Individual
Prefix:MRS
First Name:MITAL
Middle Name:RAJIV
Last Name:AMIN
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16801 NEWBURGH RD STE 114
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154-1606
Mailing Address - Country:US
Mailing Address - Phone:734-953-4155
Mailing Address - Fax:734-953-1622
Practice Address - Street 1:16801 NEWBURGH RD STE 114
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-1606
Practice Address - Country:US
Practice Address - Phone:734-953-4155
Practice Address - Fax:734-953-1622
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501010339225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA010339Medicare UPIN
MIN26170001Medicare ID - Type UnspecifiedINDIVIDUAL ID