Provider Demographics
NPI:1275617649
Name:LAWRENCE M FALLAT DPM PC
Entity Type:Organization
Organization Name:LAWRENCE M FALLAT DPM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:FALLAT
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:313-389-2288
Mailing Address - Street 1:20555 ECORSE RD
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:MI
Mailing Address - Zip Code:48180-1992
Mailing Address - Country:US
Mailing Address - Phone:313-389-2288
Mailing Address - Fax:313-389-2286
Practice Address - Street 1:20555 ECORSE RD
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180-1992
Practice Address - Country:US
Practice Address - Phone:313-389-2288
Practice Address - Fax:313-389-2286
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MILF000848213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI131352563Medicaid
MI0H27018OtherBCBS PIN
MI0H27018OtherBCBS PIN
MI131352563Medicaid