Provider Demographics
NPI:1508004920
Name:BRIAN G. LODER DPM PLC
Entity Type:Organization
Organization Name:BRIAN G. LODER DPM PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:LODER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:586-329-3895
Mailing Address - Street 1:15760 19 MILE RD STE E
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-6319
Mailing Address - Country:US
Mailing Address - Phone:586-329-3895
Mailing Address - Fax:586-329-3916
Practice Address - Street 1:43391 COMMONS DR
Practice Address - Street 2:
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48038-1109
Practice Address - Country:US
Practice Address - Phone:586-329-3895
Practice Address - Fax:586-329-3916
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-22
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901001662213ES0103X
MI332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI480E027990OtherBCBS GROUP
MIDP6530OtherRAILROAD MEDICARE
MIU53759OtherHAP
MI480E027990OtherBCN GROUP
MI1508004920Medicaid
MIDP6530OtherRAILROAD MEDICARE