Provider Demographics
NPI:1467664904
Name:SPARTAN PODIATRY PC
Entity Type:Organization
Organization Name:SPARTAN PODIATRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBIN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:269-781-4700
Mailing Address - Street 1:1600 SOUTH KALAMAZOO AVE.
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MI
Mailing Address - Zip Code:49068
Mailing Address - Country:US
Mailing Address - Phone:269-781-4700
Mailing Address - Fax:269-781-7168
Practice Address - Street 1:1600 SOUTH KALAMAZOO AVE.
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MI
Practice Address - Zip Code:49068
Practice Address - Country:US
Practice Address - Phone:269-781-4700
Practice Address - Fax:269-781-7168
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIWG000970213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI485135002OtherBCBS DR. JAMES GRAY
MI211332613Medicaid
MI485135003OtherBCBS DR. WILLIAM GRAY
MIU23882Medicare UPIN
MI485135003OtherBCBS DR. WILLIAM GRAY
MI211332613Medicaid