Provider Demographics
NPI:1245388586
Name:GREGORY H COLBERT DPM
Entity Type:Organization
Organization Name:GREGORY H COLBERT DPM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:H
Authorized Official - Last Name:COLBERT
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:517-543-0505
Mailing Address - Street 1:436 W LAWRENCE AVE
Mailing Address - Street 2:PO BOX 735
Mailing Address - City:CHARLOTTE
Mailing Address - State:MI
Mailing Address - Zip Code:48813-1442
Mailing Address - Country:US
Mailing Address - Phone:517-543-0505
Mailing Address - Fax:
Practice Address - Street 1:436 W LAWRENCE AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:MI
Practice Address - Zip Code:48813-1442
Practice Address - Country:US
Practice Address - Phone:517-543-0505
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2008-01-24
Deactivation Date:2008-01-03
Deactivation Code:
Reactivation Date:2008-01-24
Provider Licenses
StateLicense IDTaxonomies
MI5901001416213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4706341Medicaid
MI5235204Medicare PIN
MIT78847Medicare UPIN
MI5235204Medicare ID - Type UnspecifiedMEDICARE
MI5274840001Medicare NSC