Provider Demographics
NPI:1649240375
Name:ORCHARD LAKE FOOTCARE SPECIALISTS, P.L.L.C.
Entity Type:Organization
Organization Name:ORCHARD LAKE FOOTCARE SPECIALISTS, P.L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLD
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:248-682-6662
Mailing Address - Street 1:3206 ORCHARD LAKE RD
Mailing Address - Street 2:
Mailing Address - City:ORCHARD LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48324-1633
Mailing Address - Country:US
Mailing Address - Phone:248-682-6662
Mailing Address - Fax:248-682-2850
Practice Address - Street 1:3206 ORCHARD LAKE RD
Practice Address - Street 2:
Practice Address - City:ORCHARD LAKE
Practice Address - State:MI
Practice Address - Zip Code:48324-1633
Practice Address - Country:US
Practice Address - Phone:248-682-6662
Practice Address - Fax:248-682-2850
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-25
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI480F37410OtherBCBSMI
1250750001Medicare NSC
0M61370Medicare ID - Type Unspecified