Basic Information
| Provider Information | |||||||||
| NPI: | 1457421521 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PODIATRIC SURGEONS PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 324 E MAUMEE ST | ||||||||
| Address2: | |||||||||
| City: | ADRIAN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492212961 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5172653307 | ||||||||
| FaxNumber: | 5172635003 | ||||||||
| Practice Location | |||||||||
| Address1: | 324 E MAUMEE ST | ||||||||
| Address2: | |||||||||
| City: | ADRIAN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492212961 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5172653307 | ||||||||
| FaxNumber: | 5172635003 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2006 | ||||||||
| LastUpdateDate: | 11/21/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KEYS | ||||||||
| AuthorizedOfficialFirstName: | MARC | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5177887760 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DPM | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 4930320 | 05 | MI | MEDICAID | DF0052 | 01 | RAIL ROAD MR | OTHER | 1238522 | 05 | MI | MEDICAID |