Provider Demographics
NPI:1356441695
Name:FOOT AND ANKLE CLINIC OF WEST MICHIGAN,PC
Entity Type:Organization
Organization Name:FOOT AND ANKLE CLINIC OF WEST MICHIGAN,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:MAST
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:231-843-2690
Mailing Address - Street 1:333 N JEBAVY DR
Mailing Address - Street 2:
Mailing Address - City:LUDINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:49431-1923
Mailing Address - Country:US
Mailing Address - Phone:231-843-2690
Mailing Address - Fax:231-843-4338
Practice Address - Street 1:333 N JEBAVY DR
Practice Address - Street 2:
Practice Address - City:LUDINGTON
Practice Address - State:MI
Practice Address - Zip Code:49431-1923
Practice Address - Country:US
Practice Address - Phone:231-843-2690
Practice Address - Fax:231-843-4338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901001496213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2584722Medicaid
MI0E36017OtherMEDICARE ID-TYPE UNSPECIF
MIT86587Medicare UPIN
MI2584722Medicaid
MI0717580002Medicare NSC