Provider Demographics
NPI:1346430923
Name:PROFESSIONAL FOOT AND ANKLE CENTERS, PC
Entity Type:Organization
Organization Name:PROFESSIONAL FOOT AND ANKLE CENTERS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:R
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:810-653-9060
Mailing Address - Street 1:PO BOX 480
Mailing Address - Street 2:
Mailing Address - City:DAVISON
Mailing Address - State:MI
Mailing Address - Zip Code:48423-0480
Mailing Address - Country:US
Mailing Address - Phone:810-653-9060
Mailing Address - Fax:810-658-2248
Practice Address - Street 1:1390 N MAIN ST
Practice Address - Street 2:
Practice Address - City:LAPEER
Practice Address - State:MI
Practice Address - Zip Code:48446-1349
Practice Address - Country:US
Practice Address - Phone:810-664-1250
Practice Address - Fax:810-664-0315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-30
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMW001983213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4632598Medicaid
MI4632598Medicaid
MI0N88250Medicare PIN
MI5157260001Medicare NSC