1326223132 NPI number — LONG LAKE PODIATRY 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 1326223132 NPI number — LONG LAKE PODIATRY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LONG LAKE PODIATRY 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:
1326223132
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/31/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2914 E LONG LAKE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TROY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48085-3780
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-528-0709
Provider Business Mailing Address Fax Number:
248-528-1807

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2914 E LONG LAKE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TROY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48085-3780
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-528-0709
Provider Business Practice Location Address Fax Number:
248-528-1807
Provider Enumeration Date:
12/31/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BERLIN
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
H
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
248-528-0709

Provider Taxonomy Codes

  • Taxonomy code: 332BC3200X , with the licence number:  5901001005 , 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: P00245692 . This is a "RAILROAD MEDICARE PTAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 5631470 . This is a "BCROSS PIN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1634294 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 89594B . This is a "HAP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0005335144 . This is a "AETNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: NC025717 . This is a "PPOM PROVIDER CODE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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