1326223132 NPI number — LONG LAKE PODIATRY PC

Table of content: (NPI 1326223132)

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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