Provider Demographics
NPI:1295825099
Name:SUMMIT PODIATRY GROUP PC
Entity Type:Organization
Organization Name:SUMMIT PODIATRY GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISTI
Authorized Official - Middle Name:J
Authorized Official - Last Name:LEDBETTER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:517-784-0900
Mailing Address - Street 1:2797 SPRING ARBOR ROAD
Mailing Address - Street 2:SUITE A
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49203
Mailing Address - Country:US
Mailing Address - Phone:517-784-0900
Mailing Address - Fax:517-784-7835
Practice Address - Street 1:2797 SPRING ARBOR ROAD
Practice Address - Street 2:SUITE A
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49203
Practice Address - Country:US
Practice Address - Phone:517-784-0900
Practice Address - Fax:517-784-7835
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0380060001OtherMEDICARE NSC
MI0380060001OtherMEDICARE NSC