Provider Demographics
NPI:1639394851
Name:KALAMAZOO PODIATRY PC
Entity Type:Organization
Organization Name:KALAMAZOO PODIATRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:D
Authorized Official - Last Name:REDMOND
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:269-373-1019
Mailing Address - Street 1:1773 WOODSIDE TRL NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-2580
Mailing Address - Country:US
Mailing Address - Phone:616-453-1835
Mailing Address - Fax:616-453-1725
Practice Address - Street 1:333 TURWILL LN
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49006-5225
Practice Address - Country:US
Practice Address - Phone:269-373-1019
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-14
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MITR000730213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1382740Medicaid
MI5395488Medicare ID - Type Unspecified
MIT33996Medicare UPIN
MI0282240001Medicare NSC