Basic Information
| Provider Information | |||||||||
| NPI: | 1619062825 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GENE CAICCO,D.P.M., PLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11900 E 12 MILE RD | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480933487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5865737470 | ||||||||
| FaxNumber: | 5865730850 | ||||||||
| Practice Location | |||||||||
| Address1: | 11900 E 12 MILE RD | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480933487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5865737470 | ||||||||
| FaxNumber: | 5865730850 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 11/15/2012 | ||||||||
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| AuthorizedOfficialLastName: | CAICCO | ||||||||
| AuthorizedOfficialFirstName: | GENE | ||||||||
| AuthorizedOfficialMiddleName: | JOSEPH | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER PODIATRIST | ||||||||
| AuthorizedOfficialTelephone: | 5865737470 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.P.M. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 5901001745 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 4246887 | 05 | MI | MEDICAID | 48OE01215 | 01 | MI | BLUE CROSS/BLUE SHIELD | OTHER | CH7071 | 01 | MI | PALMETTO GBA | OTHER |