Provider Demographics
NPI:1225021355
Name:CANTON FOOT SPECIALIST PC
Entity Type:Organization
Organization Name:CANTON FOOT SPECIALIST PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:W
Authorized Official - Last Name:HOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-981-7800
Mailing Address - Street 1:43050 FORD RD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-3359
Mailing Address - Country:US
Mailing Address - Phone:734-981-7800
Mailing Address - Fax:734-981-0487
Practice Address - Street 1:43050 FORD RD
Practice Address - Street 2:SUITE 150
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-3359
Practice Address - Country:US
Practice Address - Phone:734-981-7800
Practice Address - Fax:734-981-0487
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-24
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901001518213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIT11641Medicare UPIN
MI4881780001Medicare NSC