1114069044 NPI number — FAMILY FOOTCARE PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114069044 NPI number — FAMILY FOOTCARE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY FOOTCARE 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:
Provider Other Organization Name Type Code:
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:
1114069044
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/07/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
29355 NORTHWESTERN HWY STE 110
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHFIELD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48034-1065
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-851-4900
Provider Business Mailing Address Fax Number:
248-945-1001

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30055 NORTHWESTERN HWY
Provider Second Line Business Practice Location Address:
SUITE L40
Provider Business Practice Location Address City Name:
FARMINGTON HILLS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48334-3230
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-851-4900
Provider Business Practice Location Address Fax Number:
248-851-4901
Provider Enumeration Date:
02/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
STERN
Authorized Official First Name:
MILTON
Authorized Official Middle Name:
J
Authorized Official Title or Position:
DOCTOR
Authorized Official Telephone Number:
248-945-1000

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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