Basic Information
| Provider Information | |||||||||
| NPI: | 1568462133 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAICCO | ||||||||
| FirstName: | GENE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11900 E 12 MILE RD | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480933400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5865737470 | ||||||||
| FaxNumber: | 5865730850 | ||||||||
| Practice Location | |||||||||
| Address1: | 11900 E 12 MILE RD | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480933400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5865737470 | ||||||||
| FaxNumber: | 5865730850 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2005 | ||||||||
| LastUpdateDate: | 10/27/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/21/2006 | ||||||||
| NPIReactivationDate: | 04/07/2006 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | GC001745 | MI | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 383523897 | 01 | MI | PPOM | OTHER | 5901001745 | 01 | MI | BCBSM | OTHER | 4246887 | 05 | MI | MEDICAID | 383523897 | 01 | MI | ST JOHN SMART PLAN | OTHER | 383523897 | 01 | MI | UNITED HEALTH CARE | OTHER |