Provider Demographics
NPI:1033219209
Name:TROY PODIATRIST PC
Entity Type:Organization
Organization Name:TROY PODIATRIST PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:GLICKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:248-689-5125
Mailing Address - Street 1:4770 ROCHESTER RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48085-4951
Mailing Address - Country:US
Mailing Address - Phone:248-689-5125
Mailing Address - Fax:248-689-5688
Practice Address - Street 1:4770 ROCHESTER RD
Practice Address - Street 2:SUITE 104
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48085-4951
Practice Address - Country:US
Practice Address - Phone:248-689-5125
Practice Address - Fax:248-689-5688
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2009-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISG000600213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1375192-13Medicaid
MIC2490OtherMCARE
MI480013308OtherRAILROAD MEDICARE
MIT34182Medicare UPIN
MI480013308OtherRAILROAD MEDICARE
MI0F37223Medicare ID - Type Unspecified