Provider Demographics
NPI:1851027866
Name:PREMIER FOOT & ANKLE, PLLC
Entity Type:Organization
Organization Name:PREMIER FOOT & ANKLE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAHOFSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-948-9417
Mailing Address - Street 1:17900 23 MILE RD STE 204
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48044-1161
Mailing Address - Country:US
Mailing Address - Phone:586-948-9417
Mailing Address - Fax:586-846-3910
Practice Address - Street 1:18010 MACK AVE
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE
Practice Address - State:MI
Practice Address - Zip Code:48230-6235
Practice Address - Country:US
Practice Address - Phone:313-882-7480
Practice Address - Fax:313-882-7525
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PREMIER FOOT & ANKLE GROSSE POINT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-08-01
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1851846257Medicaid