Provider Demographics
NPI:1336252857
Name:PODIATRY EXAMINERS OF MICHIGAN PC
Entity Type:Organization
Organization Name:PODIATRY EXAMINERS OF MICHIGAN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:MARSHALL
Authorized Official - Last Name:GASTWIRTH
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:313-833-3090
Mailing Address - Street 1:3800 WOODWARD AVENUE
Mailing Address - Street 2:SUITE 318
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2066
Mailing Address - Country:US
Mailing Address - Phone:313-833-3096
Mailing Address - Fax:313-833-7843
Practice Address - Street 1:3800 WOODWARD AVENUE
Practice Address - Street 2:SUITE 318
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2066
Practice Address - Country:US
Practice Address - Phone:313-833-3096
Practice Address - Fax:313-833-7843
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0814213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0961720001OtherDMERC
U23902OtherHEALTH ALLIANCE PLAN
MI4888250510OtherBLUE CROSS
002631OtherMIDWEST HEALTH PLAN
MI1260775Medicaid
15982OtherCAPE HEALTH PLAN
123985OtherWELLNESS PLAN
20094OtherOMICARE HEALTH PLAN
P00248OtherHUMANA CHOICE CARE
MI1260775Medicaid
U23902Medicare UPIN
002631OtherMIDWEST HEALTH PLAN
MI8825051Medicare ID - Type Unspecified
MI1260775Medicaid