Provider Demographics
NPI:1841576998
Name:GRAND LAKE FOOT & ANKLE INC
Entity Type:Organization
Organization Name:GRAND LAKE FOOT & ANKLE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DPM
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:BENJAMIN SWONGER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:419-586-7874
Mailing Address - Street 1:1222 IRMSCHER BLVD
Mailing Address - Street 2:
Mailing Address - City:CELINA
Mailing Address - State:OH
Mailing Address - Zip Code:45822-8305
Mailing Address - Country:US
Mailing Address - Phone:419-586-7874
Mailing Address - Fax:419-586-2776
Practice Address - Street 1:1222 IRMSCHER BLVD
Practice Address - Street 2:
Practice Address - City:CELINA
Practice Address - State:OH
Practice Address - Zip Code:45822-8305
Practice Address - Country:US
Practice Address - Phone:419-586-7874
Practice Address - Fax:419-586-2776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-02
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36002772213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0061420Medicaid
OH0061420Medicaid
OHDT5915Medicare PIN
OH6758710001Medicare NSC