Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251X0800X | Physical Therapist - Orthopedic | 5501005513 | MI |
NPI | 1073590980 |
---|---|
Provider Name | Mr. Mark Campbell Miles |
First Address | Marquette, MI 49855-9390 |
Second Address | Marquette, MI 49855-8859 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/12/2005 |
Last Update Date | 04/12/2007 |