Provider Demographics
NPI:1649242058
Name:PODIATRIC SURGEONS PC
Entity Type:Organization
Organization Name:PODIATRIC SURGEONS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:S
Authorized Official - Last Name:KEYS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:517-788-7760
Mailing Address - Street 1:823 E MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-2401
Mailing Address - Country:US
Mailing Address - Phone:517-788-7760
Mailing Address - Fax:517-788-7730
Practice Address - Street 1:823 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-2401
Practice Address - Country:US
Practice Address - Phone:517-788-7760
Practice Address - Fax:517-788-7730
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-02
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DF0052OtherRAIL ROAD MR
MI3296294Medicaid
MI4930295Medicaid
MI4930295Medicaid
MI3296294Medicaid