Provider Demographics
NPI:1467625723
Name:PODIATRY WEST SENIOR FOOT CARE SERVICES PLLC
Entity Type:Organization
Organization Name:PODIATRY WEST SENIOR FOOT CARE SERVICES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:616-456-9744
Mailing Address - Street 1:56 BENJAMIN AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-1628
Mailing Address - Country:US
Mailing Address - Phone:616-456-9744
Mailing Address - Fax:616-451-0717
Practice Address - Street 1:56 BENJAMIN AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-1628
Practice Address - Country:US
Practice Address - Phone:616-456-9744
Practice Address - Fax:616-451-0717
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-08
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901001622213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4461768Medicaid
MI0N56790Medicare PIN
MIU25165Medicare UPIN