Provider Demographics
NPI:1568501062
Name:DELTA FOOT CARE, P.C.
Entity Type:Organization
Organization Name:DELTA FOOT CARE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:SPENCER
Authorized Official - Last Name:GOOSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:517-485-7300
Mailing Address - Street 1:3802 W KALAMAZOO ST
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48917-3653
Mailing Address - Country:US
Mailing Address - Phone:517-485-7300
Mailing Address - Fax:517-485-7301
Practice Address - Street 1:3802 W KALAMAZOO ST
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48917-3653
Practice Address - Country:US
Practice Address - Phone:517-485-7300
Practice Address - Fax:517-485-7301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2009-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIBG001798213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P00920OtherMEDICARE SECONDARY PAYOR
MI480B310270OtherBLUE CARE NETWORK
MI480B310270OtherBCN ADVANTAGE
MI17738OtherPRIORITY HEALTH
MI201749OtherMEDICAID MCLAREN
MI17738OtherPRIORITY HEALTH
MI480B310270OtherBCN ADVANTAGE