Provider Demographics
NPI:1861721656
Name:PERIYASAMY, VINOTH (MPT)
Entity type:Individual
Prefix:
First Name:VINOTH
Middle Name:
Last Name:PERIYASAMY
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2445 TAVISTOCK CT
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48310-7109
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2445 TAVISTOCK CT
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48310-7109
Practice Address - Country:US
Practice Address - Phone:248-764-0700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-08
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501013741225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI08111978Medicaid
MI08111978Medicare PIN
MI08111978Medicare Oscar/Certification
MI08111978Medicaid
MI0008111978Medicare NSC