Provider Demographics
NPI:1417908633
Name:SOUTHWEST FOOT & ANKLE SPECIALISTS, PC
Entity Type:Organization
Organization Name:SOUTHWEST FOOT & ANKLE SPECIALISTS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:M
Authorized Official - Last Name:WHITAKER BAY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:269-385-1000
Mailing Address - Street 1:515 HOWARD ST
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49008-1917
Mailing Address - Country:US
Mailing Address - Phone:269-385-1000
Mailing Address - Fax:269-385-5120
Practice Address - Street 1:515 HOWARD ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49008-1917
Practice Address - Country:US
Practice Address - Phone:269-385-1000
Practice Address - Fax:269-385-5120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MITW002034213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4841159Medicaid
MI480C912300OtherBCBS
MI480C912300OtherBCBS
MIOP15440Medicare ID - Type Unspecified
MI5446390001Medicare NSC