Provider Demographics
NPI:1538285036
Name:MICHIGAN ASSOCIATES IN PODIATRIC MEDICINE AND SURGERY PC
Entity Type:Organization
Organization Name:MICHIGAN ASSOCIATES IN PODIATRIC MEDICINE AND SURGERY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DINA
Authorized Official - Middle Name:M
Authorized Official - Last Name:JEGLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-674-2575
Mailing Address - Street 1:5379 PLEASANT LAKE DR
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-4715
Mailing Address - Country:US
Mailing Address - Phone:248-674-2575
Mailing Address - Fax:248-674-0577
Practice Address - Street 1:3560 PONTIAC LAKE RD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48328-2337
Practice Address - Country:US
Practice Address - Phone:248-674-2575
Practice Address - Fax:248-674-0577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2010-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI000581213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI094460OtherMEDICARE PTAN
MI427339213Medicaid
MI427339213Medicaid