Provider Demographics
NPI:1760529705
Name:BLUE WATER PODIATRY PC
Entity Type:Organization
Organization Name:BLUE WATER PODIATRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:K
Authorized Official - Last Name:ERNST
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:810-982-4240
Mailing Address - Street 1:5303 SHOREWOOD DR
Mailing Address - Street 2:
Mailing Address - City:FORT GRATIOT
Mailing Address - State:MI
Mailing Address - Zip Code:48059-3137
Mailing Address - Country:US
Mailing Address - Phone:810-385-2053
Mailing Address - Fax:
Practice Address - Street 1:828 10TH AVE
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3640
Practice Address - Country:US
Practice Address - Phone:810-982-4240
Practice Address - Fax:810-982-2479
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI59000955213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1958336Medicaid
MIT99302Medicare UPIN
MIP44880001Medicare PIN
MI0423900001Medicare NSC