Provider Demographics
NPI:1518093400
Name:AUBURN ADULT FOOT CARE, P C
Entity Type:Organization
Organization Name:AUBURN ADULT FOOT CARE, P C
Other - Org Name:MADISON PODIATRY ASSOCIATES, P C
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOB
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:248-739-0159
Mailing Address - Street 1:6689 ORCHARD LAKE ROAD # 302
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322
Mailing Address - Country:US
Mailing Address - Phone:248-757-0030
Mailing Address - Fax:248-757-0025
Practice Address - Street 1:4319 FOXPOINTE DR
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48323-2615
Practice Address - Country:US
Practice Address - Phone:248-757-0030
Practice Address - Fax:248-757-0025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901000789213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N71010Medicare PIN
MIT33407Medicare UPIN