Provider Demographics
NPI:1316191679
Name:GFC OF SOUTHEASTERN MICHIGAN, PC
Entity Type:Organization
Organization Name:GFC OF SOUTHEASTERN MICHIGAN, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MANISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:MEHTA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:313-833-3090
Mailing Address - Street 1:15 E KIRBY ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-4047
Mailing Address - Country:US
Mailing Address - Phone:313-833-3090
Mailing Address - Fax:313-833-7843
Practice Address - Street 1:15 E KIRBY ST
Practice Address - Street 2:SUITE 102
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-4047
Practice Address - Country:US
Practice Address - Phone:313-833-3090
Practice Address - Fax:313-833-7843
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-12
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901002275213ES0103X
335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No335E00000XSuppliersProsthetic/Orthotic SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1417136029Medicaid
MI82028141OtherPROCARE
MI1316191679OtherMEDICARE NPI
MIMI1225001Medicare PIN
MI82028141OtherPROCARE
MIMI1225Medicare PIN