1164694428 NPI number — GRAND LAKE PODIATRY, INC

Table of content: (NPI 1164694428)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164694428 NPI number — GRAND LAKE PODIATRY, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRAND LAKE PODIATRY, INC
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:
1164694428
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/18/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1222 IRMSCHER BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CELINA
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45822-8305
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-586-7874
Provider Business Mailing Address Fax Number:
419-586-2776

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6 EAGLE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MINSTER
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45865-9714
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-628-7874
Provider Business Practice Location Address Fax Number:
419-628-4620
Provider Enumeration Date:
03/27/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BENJAMIN-SWONGER
Authorized Official First Name:
MARY
Authorized Official Middle Name:
KATHERINE
Authorized Official Title or Position:
PODIATRIST/OWNER-PRESIDENT
Authorized Official Telephone Number:
419-586-7874

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  36 002772 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2544876 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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