Provider Demographics
NPI:1134237639
Name:PODIATRIC MEDICAL ASSOCIATES PC
Entity type:Organization
Organization Name:PODIATRIC MEDICAL ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:K
Authorized Official - Last Name:GRANDFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:219-736-8915
Mailing Address - Street 1:303 W 89TH AVE
Mailing Address - Street 2:SUITE E-1
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410
Mailing Address - Country:US
Mailing Address - Phone:219-736-8915
Mailing Address - Fax:219-736-8928
Practice Address - Street 1:303 W 89TH AVE
Practice Address - Street 2:SUITE E-1
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410
Practice Address - Country:US
Practice Address - Phone:219-736-8915
Practice Address - Fax:219-736-8928
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-26
Last Update Date:2013-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07000353A213E00000X
IN07000785A213E00000X
IN07000922A213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000084758OtherANTHEM
IN200326020Medicaid
1089370001OtherMEDICARE DMERC
IN000000084756OtherANTHEM
480016271OtherRR MEDICARE
480032400OtherRR MEDICARE
480020342OtherRR MEDICARE
IN00000209276OtherANTHEM
IN100148090Medicaid
IN100207960Medicaid
U43202Medicare UPIN
IN200326020Medicaid
480016271OtherRR MEDICARE
IN000000084758OtherANTHEM
1089370001OtherMEDICARE DMERC
492470DMedicare ID - Type Unspecified
492470EMedicare ID - Type Unspecified