Provider Demographics
NPI:1619062825
Name:GENE CAICCO,D.P.M., PLC
Entity Type:Organization
Organization Name:GENE CAICCO,D.P.M., PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GENE
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:CAICCO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:586-573-7470
Mailing Address - Street 1:11900 E 12 MILE RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-3487
Mailing Address - Country:US
Mailing Address - Phone:586-573-7470
Mailing Address - Fax:586-573-0850
Practice Address - Street 1:11900 E 12 MILE RD
Practice Address - Street 2:SUITE 102
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-3487
Practice Address - Country:US
Practice Address - Phone:586-573-7470
Practice Address - Fax:586-573-0850
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901001745213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4246887Medicaid
MI48OE01215OtherBLUE CROSS/BLUE SHIELD
MICH7071OtherPALMETTO GBA
MIU61949Medicare UPIN
MI4246887Medicaid
MI4070840001Medicare NSC