Provider Demographics
NPI:1255425088
Name:PENINSULA PODIATRY LLC
Entity type:Organization
Organization Name:PENINSULA PODIATRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:GERARD
Authorized Official - Last Name:BURKART
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:920-743-6668
Mailing Address - Street 1:BLDG 4 2
Mailing Address - Street 2:30 NORTH 18TH AVENUE
Mailing Address - City:STURGEON BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54235-3207
Mailing Address - Country:US
Mailing Address - Phone:920-743-6668
Mailing Address - Fax:920-743-9222
Practice Address - Street 1:BLDG 4 2
Practice Address - Street 2:30 NORTH 18TH AVENUE
Practice Address - City:STURGEON BAY
Practice Address - State:WI
Practice Address - Zip Code:54235-3207
Practice Address - Country:US
Practice Address - Phone:920-743-6668
Practice Address - Fax:920-743-9222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI332B00000X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43267300Medicaid
WI82460Medicare PIN
WI5377870001Medicare NSC