Provider Demographics
NPI:1548330848
Name:NESAM CONCEPTS PHYSICAL THERAPY& REHABILITATION
Entity type:Organization
Organization Name:NESAM CONCEPTS PHYSICAL THERAPY& REHABILITATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:EDEWOR
Authorized Official - Middle Name:SPLENDID
Authorized Official - Last Name:NANA
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:313-388-7110
Mailing Address - Street 1:752 SOUTHFIELD ROAD
Mailing Address - Street 2:
Mailing Address - City:LINCOLN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48146
Mailing Address - Country:US
Mailing Address - Phone:313-388-7110
Mailing Address - Fax:313-388-7424
Practice Address - Street 1:17500 NORTHLAND PARK CT STE 1
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-4324
Practice Address - Country:US
Practice Address - Phone:313-388-7110
Practice Address - Fax:313-388-7424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI55010064442251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4297616Medicaid
P112871OtherBSBS
MI4297616Medicaid
MI4297616Medicaid