Provider Demographics
NPI:1245376102
Name:GRANDVIEW FOOT AND ANKLE PC
Entity type:Organization
Organization Name:GRANDVIEW FOOT AND ANKLE PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:AARON
Authorized Official - Last Name:UEBELE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:269-948-9155
Mailing Address - Street 1:PO BOX 362
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49058-0362
Mailing Address - Country:US
Mailing Address - Phone:269-948-9155
Mailing Address - Fax:269-948-9577
Practice Address - Street 1:1005 W GREEN ST
Practice Address - Street 2:SUITE NUMBER 304
Practice Address - City:HASTINGS
Practice Address - State:MI
Practice Address - Zip Code:49058-1712
Practice Address - Country:US
Practice Address - Phone:269-948-9155
Practice Address - Fax:269-948-9577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISU001970213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4766591Medicaid
MI4710193Medicaid
MI4710219Medicaid
MIU86206Medicare UPIN
MIP02180001Medicare ID - Type Unspecified
MI4710193Medicaid