Provider Demographics
NPI:1518992536
Name:LAKEVIEW PODIATRY ASSOC P C
Entity Type:Organization
Organization Name:LAKEVIEW PODIATRY ASSOC P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:GUY
Authorized Official - Middle Name:
Authorized Official - Last Name:PUPP
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:248-424-8637
Mailing Address - Street 1:22250 PROVIDENCE DR STE 100
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-6209
Mailing Address - Country:US
Mailing Address - Phone:248-424-8637
Mailing Address - Fax:248-424-8663
Practice Address - Street 1:22250 PROVIDENCE DR STE 100
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-6209
Practice Address - Country:US
Practice Address - Phone:248-424-8637
Practice Address - Fax:248-424-8663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2017-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901000690213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M07610OtherMEDICARE
MI0H2788OtherBCBSM
MI4275305Medicaid
MIT34213OtherHAP PROVIDER #
MI0H2788OtherBCBSM
MI4791160001Medicare NSC
MI=========OtherTAX ID NUMBER