Provider Demographics
NPI:1114239886
Name:PODCARE
Entity Type:Organization
Organization Name:PODCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:REPITOR
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:989-791-2455
Mailing Address - Street 1:3061 CHRISTY WAY
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48603-2267
Mailing Address - Country:US
Mailing Address - Phone:989-791-2455
Mailing Address - Fax:989-791-1392
Practice Address - Street 1:21327 HARPER AVE
Practice Address - Street 2:SUITE C
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-2200
Practice Address - Country:US
Practice Address - Phone:989-791-2455
Practice Address - Fax:989-791-2455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-09
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISR400227213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1194760835Medicaid
MIT34208Medicare UPIN
MI1194760835Medicaid