NPIMap

Organization Active NPI

Health Source Physical Therapy Center, Inc.

  • Physical Therapy Clinic/Center
  • Portland, MI
National Provider Identifier
1083624969
Registry record updated Dec 20, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physical Therapy Clinic/CenterTaxonomy code 261QP2000X
License
5501005495 Issued in MI
Legal business name
HEALTH SOURCE PHYSICAL THERAPY CENTER, INC.
Practice address
1447 E Grand River Ave
Portland, MI 48875-1631
Phone
(517) 647-1000
Fax
(517) 647-1100
NPI assigned
Aug 9, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 20, 2011

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Jaya P BodduNPI 1023235777
Title
President
Phone
(517) 647-1000

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Physical Therapy Clinic/Center 261QP2000X 5501005495 MI Primary

Addresses

Primary practice location

1447 E Grand River Ave
Portland, MI 48875-1631

Mailing address

1447 E Grand River Ave
Portland, MI 48875-1631
Phone (517) 647-1000

Other identifiers 6

IdentifierTypeStateIssuer
30472OtherMIBCN
P109760OtherMIBCN
64-00030OtherMIPHP
650C457010OtherMIBCBS
10-4266217MedicaidMI
5501005495OtherMIPRIORITY HEALTH

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MI

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20111121000446 MI Part A Provider - Outpatient Physical Therapy/Occupational Therapy/Speech Pathology Services 3971777335 Practice locations: Portland, MI

Outpatient physical therapy / speech pathology certification: CCN 236800

Name & address match This certification has no NPI in the Medicare enrollment files. CMS publishes enrollment files for six facility types only, so it was connected to this NPI by matching the name and address CMS publishes for it.

Legal name
HEALTH SOURCE PHYSICAL THERAPY CENTER
Certification status
Active
Provider type (POS)
Outpatient physical therapy / speech pathology
Participating since
May 28, 2002
Last certification
Jun 6, 2023
Ownership / control type
Proprietary
Facility address
1447 East Grand River Avenue
Portland, MI 48875

National Provider Directory

National Provider Directory

Locations

1447 E Grand River Ave
Portland, MI 48875
Phone (517) 647-1000

Practitioners & affiliated clinicians

Practitioners 5

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1155081600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1324339200000",
    "number": "1083624969",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1447 E GRAND RIVER AVE",
            "city": "PORTLAND",
            "state": "MI",
            "postal_code": "488751631",
            "telephone_number": "517-647-1000",
            "fax_number": "517-647-1100"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1447 E GRAND RIVER AVE",
            "city": "PORTLAND",
            "state": "MI",
            "postal_code": "488751631",
            "telephone_number": "517-647-1000",
            "fax_number": "517-647-1100"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "HEALTH SOURCE PHYSICAL THERAPY CENTER, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-08-09",
        "last_updated": "2011-12-20",
        "status": "A",
        "authorized_official_last_name": "BODDU",
        "authorized_official_first_name": "JAYA",
        "authorized_official_middle_name": "P",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "517-647-1000",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "261QP2000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Physical Therapy",
            "state": "MI",
            "license": "5501005495",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCN",
            "identifier": "30472",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCN",
            "identifier": "P109760",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PHP",
            "identifier": "64-00030",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS",
            "identifier": "650C457010",
            "state": "MI"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "10-4266217",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PRIORITY HEALTH",
            "identifier": "5501005495",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Portland, MI

Sources for this page

Verify at the official NPI Registry.