Provider Demographics
NPI:1396036604
Name:U.P. PODIATRY
Entity Type:Organization
Organization Name:U.P. PODIATRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:D
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:248-996-6465
Mailing Address - Street 1:23999 NORTHWESTERN HIGHWAY
Mailing Address - Street 2:SUITE 220
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075
Mailing Address - Country:US
Mailing Address - Phone:248-996-6465
Mailing Address - Fax:248-996-6469
Practice Address - Street 1:23999 NORTHWESTERN HWY
Practice Address - Street 2:SUITE 220
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-2578
Practice Address - Country:US
Practice Address - Phone:248-996-6465
Practice Address - Fax:248-996-6469
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-21
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901001869213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty