Provider Demographics
NPI:1538331525
Name:GRAND LAKE PODIATRY, INC
Entity Type:Organization
Organization Name:GRAND LAKE PODIATRY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST/OWNER-PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:KATHERINE
Authorized Official - Last Name:BENJAMIN-SWONGER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:419-586-7874
Mailing Address - Street 1:1222 IRMSCHER BLVD
Mailing Address - Street 2:
Mailing Address - City:CELINA
Mailing Address - State:OH
Mailing Address - Zip Code:45822-8305
Mailing Address - Country:US
Mailing Address - Phone:419-586-7874
Mailing Address - Fax:416-586-2776
Practice Address - Street 1:812 REDSKIN TRL
Practice Address - Street 2:STE B
Practice Address - City:WAPAKONETA
Practice Address - State:OH
Practice Address - Zip Code:45895-8545
Practice Address - Country:US
Practice Address - Phone:419-586-7874
Practice Address - Fax:419-586-2776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-31
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36 002772213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2544901Medicaid
OH2544901Medicaid
OH9285764Medicare PIN
1153470005Medicare NSC