1477690428 NPI number — GRANDVIEW FOOT AND ANKLE PC

Table of content: (NPI 1477690428)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477690428 NPI number — GRANDVIEW FOOT AND ANKLE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRANDVIEW FOOT AND ANKLE PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
STACY A UEBELE DPM
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477690428
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/10/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 362
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HASTINGS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49058-0362
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-948-9155
Provider Business Mailing Address Fax Number:
269-948-9577

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
231 W PINE LAKE DR
Provider Second Line Business Practice Location Address:
SUITE NUMBER 102
Provider Business Practice Location Address City Name:
NEWAYGO
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49337-8028
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-652-5955
Provider Business Practice Location Address Fax Number:
231-652-5956
Provider Enumeration Date:
01/31/2007

Additional Information

Authorized Official

Authorized Official Last Name:
UEBELE
Authorized Official First Name:
STACY
Authorized Official Middle Name:
AARON
Authorized Official Title or Position:
PODIATRIST
Authorized Official Telephone Number:
269-948-9155

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  SU001970 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4710219 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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