Provider Demographics
NPI:1164499323
Name:MARY FREE BED REHABILITATION, LLC
Entity type:Organization
Organization Name:MARY FREE BED REHABILITATION, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PODVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-840-8877
Mailing Address - Street 1:866 3 MILE RD NW
Mailing Address - Street 2:SUITE A
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49544-8217
Mailing Address - Country:US
Mailing Address - Phone:616-647-4618
Mailing Address - Fax:616-464-3581
Practice Address - Street 1:866 3 MILE RD NW
Practice Address - Street 2:SUITE A
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49544-8217
Practice Address - Country:US
Practice Address - Phone:616-647-4618
Practice Address - Fax:616-464-3581
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-07
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI650D157230OtherBCN
MI650D157230OtherBCBSM
0N27500Medicare PIN