Provider Demographics
NPI:1558553628
Name:DIABETIC FOOT PLLC
Entity Type:Organization
Organization Name:DIABETIC FOOT PLLC
Other - Org Name:DIABETIC FOOT MANAGEMENT CENTER OF MI
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:ELAINE
Authorized Official - Last Name:HOLIBAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:231-733-1511
Mailing Address - Street 1:1281 E SHERMAN BLVD
Mailing Address - Street 2:PO BOX 4344
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49444-1846
Mailing Address - Country:US
Mailing Address - Phone:231-733-1511
Mailing Address - Fax:231-733-7980
Practice Address - Street 1:1281 E SHERMAN BLVD
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-1846
Practice Address - Country:US
Practice Address - Phone:231-733-1511
Practice Address - Fax:231-733-7980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-13
Last Update Date:2007-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISH001528213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2693057Medicaid
1235107632OtherNPI TYPE I
MI2693057Medicaid