Provider Demographics
NPI:1134126386
Name:MALA PODIATRIC SERVICES,LLC
Entity Type:Organization
Organization Name:MALA PODIATRIC SERVICES,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OLEH
Authorized Official - Middle Name:ROMAN
Authorized Official - Last Name:LAWRIN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:586-759-4170
Mailing Address - Street 1:4595 NATHAN W
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48310-2658
Mailing Address - Country:US
Mailing Address - Phone:586-759-4170
Mailing Address - Fax:586-759-0150
Practice Address - Street 1:4595 NATHAN W
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48310-2658
Practice Address - Country:US
Practice Address - Phone:586-759-4170
Practice Address - Fax:586-759-0150
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-01
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI400101213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI134756639Medicaid
MI134756639Medicaid
MIT34051Medicare UPIN
MI134756639Medicaid
MI480E016790OtherBCBS PIN