Provider Demographics
NPI:1184835340
Name:SPECIALIZED PODIATRY SERVICES P. C.
Entity Type:Organization
Organization Name:SPECIALIZED PODIATRY SERVICES P. C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARC
Authorized Official - Middle Name:
Authorized Official - Last Name:WEINER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:2489-322-6078
Mailing Address - Street 1:2035 WICKFORD CT
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48304-1088
Mailing Address - Country:US
Mailing Address - Phone:248-932-2607
Mailing Address - Fax:
Practice Address - Street 1:2035 WICKFORD CT
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48304-1088
Practice Address - Country:US
Practice Address - Phone:248-932-2607
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-26
Last Update Date:2012-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMW000841213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMW000841OtherSTATE LICENSE
MIMW000841OtherSTATE LICENSE
MI0N28240Medicare ID - Type Unspecified