Provider Demographics
NPI:1851307573
Name:SKROCKI, GERARD JOHN (DPM)
Entity Type:Individual
Prefix:
First Name:GERARD
Middle Name:JOHN
Last Name:SKROCKI
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:GERARD
Other - Middle Name:JOHN
Other - Last Name:SKROCKI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPM
Mailing Address - Street 1:42370 VAN DYKE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48314
Mailing Address - Country:US
Mailing Address - Phone:586-254-2211
Mailing Address - Fax:586-254-2297
Practice Address - Street 1:42370 VAN DYKE
Practice Address - Street 2:SUITE 104
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48314
Practice Address - Country:US
Practice Address - Phone:586-254-2211
Practice Address - Fax:586-254-2297
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIGS000898213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2101773Medicaid
T34056Medicare UPIN
5505121Medicare ID - Type Unspecified