Basic Information
| Provider Information | |||||||||
| NPI: | 1790702587 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHRISTIN | ||||||||
| FirstName: | GLORIA | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 831 | ||||||||
| Address2: | |||||||||
| City: | PERRYSBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435520831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346995182 | ||||||||
| FaxNumber: | 4198850203 | ||||||||
| Practice Location | |||||||||
| Address1: | 1194 HILLSIDE DR | ||||||||
| Address2: | |||||||||
| City: | MILFORD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483811011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346995182 | ||||||||
| FaxNumber: | 4198850203 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2006 | ||||||||
| LastUpdateDate: | 10/02/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 001748 | MI | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | 213E00000X | 36002682 | OH | N | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 480018804 | 01 | RAILROAD MEDICARE | OTHER | 0841030 | 05 | OH | MEDICAID |