Provider Demographics
NPI:1891863726
Name:ADVANCED PODIATRY OF DEARBORN PC
Entity Type:Organization
Organization Name:ADVANCED PODIATRY OF DEARBORN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:248-737-2343
Mailing Address - Street 1:7296 SIMSBURY DR
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-3548
Mailing Address - Country:US
Mailing Address - Phone:248-737-2343
Mailing Address - Fax:248-737-3959
Practice Address - Street 1:7296 SIMSBURY DR
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-3548
Practice Address - Country:US
Practice Address - Phone:248-737-2343
Practice Address - Fax:248-737-3959
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2008-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901000677213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI8825444OtherBLUE CROSS & BLUE SHIELD
MI1080580Medicaid
MI4333620001Medicare NSC
T78250Medicare UPIN
MI0P49320Medicare PIN