1720380975 NPI number — BC PODIATRY PLLC

Table of content: (NPI 1720380975)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720380975 NPI number — BC PODIATRY PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BC PODIATRY PLLC
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:
6
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:
1720380975
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/22/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4123 MARTIN RD
Provider Second Line Business Mailing Address:
STE 101
Provider Business Mailing Address City Name:
COMMERCE TOWNSHIP
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48390-4151
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-363-3777
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
89 W SOUTH BLVD
Provider Second Line Business Practice Location Address:
STE. 500
Provider Business Practice Location Address City Name:
TROY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48085-1611
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-509-7086
Provider Business Practice Location Address Fax Number:
248-289-1853
Provider Enumeration Date:
11/20/2010

Additional Information

Authorized Official

Authorized Official Last Name:
DPM
Authorized Official First Name:
BRIAN
Authorized Official Middle Name:
BURKARDT
Authorized Official Title or Position:
OWNER/PHYSICAN
Authorized Official Telephone Number:
734-308-2973

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 335E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 6242670004 . This is a "MEDICARE DMEPOS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 480F337000 . This is a "BLUE CARE NETWORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 480F394240 . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0P41010 . This is a "MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 480F337000 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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