Provider Demographics
NPI:1790989549
Name:LARRY R WALTON
Entity Type:Organization
Organization Name:LARRY R WALTON
Other - Org Name:HAND SURGERY CENTER OF SOUTHWEST MI
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:RAYMOND
Authorized Official - Last Name:WALTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:269-382-9900
Mailing Address - Street 1:1220 WEST MILHAM AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-1206
Mailing Address - Country:US
Mailing Address - Phone:269-382-9900
Mailing Address - Fax:269-382-0700
Practice Address - Street 1:1220 WEST MILHAM AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-1206
Practice Address - Country:US
Practice Address - Phone:269-382-9900
Practice Address - Fax:269-382-0700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-14
Last Update Date:2011-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI039773207XS0106X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand SurgeryGroup - Single Specialty
No335E00000XSuppliersProsthetic/Orthotic SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI039279OtherBCBS
MI4079644Medicaid
MI4495410001Medicare NSC
MI0N56560Medicare PIN
MI039279OtherBCBS