Provider Demographics
NPI:1396928297
Name:GRAND TRAVERSE FOOT & ANKLE CENTER P.C.
Entity type:Organization
Organization Name:GRAND TRAVERSE FOOT & ANKLE CENTER P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:ZYWICKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-922-9100
Mailing Address - Street 1:4246 N. THREE MILE RD.
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686
Mailing Address - Country:US
Mailing Address - Phone:231-922-9100
Mailing Address - Fax:231-922-9180
Practice Address - Street 1:4246 N. THREE MILE RD.
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686
Practice Address - Country:US
Practice Address - Phone:231-922-9100
Practice Address - Fax:231-922-9180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-13
Last Update Date:2013-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901001664213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI132893049Medicaid
MIU13351Medicare UPIN
MI132893049Medicaid
MI0P52510Medicare PIN