Provider Demographics
NPI:1790883056
Name:ALLEN PARK FOOTCARE SPECIALIST PLLC
Entity Type:Organization
Organization Name:ALLEN PARK FOOTCARE SPECIALIST PLLC
Other - Org Name:BRIAN E. HOMER
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:HOMER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM, PC
Authorized Official - Phone:248-288-8900
Mailing Address - Street 1:19250 ECORSE RD
Mailing Address - Street 2:
Mailing Address - City:ALLEN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48101-2260
Mailing Address - Country:US
Mailing Address - Phone:313-294-9700
Mailing Address - Fax:313-294-9700
Practice Address - Street 1:19250 ECORSE RD
Practice Address - Street 2:
Practice Address - City:ALLEN PARK
Practice Address - State:MI
Practice Address - Zip Code:48101-2260
Practice Address - Country:US
Practice Address - Phone:313-294-9700
Practice Address - Fax:313-294-9700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901001699261QP1100X, 332B00000X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI133153308Medicaid
MI4319060001OtherMEDICARE DME
MI0H20650OtherBCBSMI DME
MIP00102057OtherRAILROAD MEDICARE
MI0H218370OtherBCBSMI
MI0H20650OtherBCBSMI DME
MI133153308Medicaid