Provider Demographics
NPI:1184618811
Name:GRODMAN, SCOTT T (DPM)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:T
Last Name:GRODMAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9300 PARDEE RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:TAYLOR
Mailing Address - State:MI
Mailing Address - Zip Code:48180-3528
Mailing Address - Country:US
Mailing Address - Phone:313-295-1620
Mailing Address - Fax:313-295-1622
Practice Address - Street 1:9300 PARDEE RD
Practice Address - Street 2:SUITE A
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180-3528
Practice Address - Country:US
Practice Address - Phone:313-295-1620
Practice Address - Fax:313-295-1622
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-08
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5901001478213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0H22790OtherBC DME
MI48-0H244260OtherBC
MI2948227Medicaid
MI4858213180OtherBC
MIU13282Medicare UPIN
MI0N20760Medicare PIN