Provider Demographics
NPI:1093991101
Name:MEDIC PODIATRY AND WOUND CARE
Entity Type:Organization
Organization Name:MEDIC PODIATRY AND WOUND CARE
Other - Org Name:MICHAEL R METYK DPM
Other - Org Type:Other Name
Authorized Official - Title/Position:PODIATRIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:METYK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:941-613-1919
Mailing Address - Street 1:3191 HARBOR BLVD
Mailing Address - Street 2:UNIT D
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-6755
Mailing Address - Country:US
Mailing Address - Phone:941-613-1919
Mailing Address - Fax:941-613-4077
Practice Address - Street 1:3191 HARBOR BLVD
Practice Address - Street 2:UNIT D
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-6755
Practice Address - Country:US
Practice Address - Phone:941-613-1919
Practice Address - Fax:941-613-4077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-18
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO2884213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL480031773OtherRAILROAD MEDICARE
FL4239450001Medicare NSC