Provider Demographics
NPI:1396946265
Name:SCOTT T GRODMAN DPM PC
Entity type:Organization
Organization Name:SCOTT T GRODMAN DPM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:T
Authorized Official - Last Name:GRODMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:248-547-2450
Mailing Address - Street 1:3055 HILTON RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:FERNDALE
Mailing Address - State:MI
Mailing Address - Zip Code:48220-1096
Mailing Address - Country:US
Mailing Address - Phone:248-547-2450
Mailing Address - Fax:
Practice Address - Street 1:3055 HILTON RD
Practice Address - Street 2:SUITE C
Practice Address - City:FERNDALE
Practice Address - State:MI
Practice Address - Zip Code:48220-1096
Practice Address - Country:US
Practice Address - Phone:248-547-2450
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-30
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI001478213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI540H227900OtherBC DME
MI4858213180OtherBCBS
MI2948227Medicaid
MI2948227Medicaid
MI540H227900OtherBC DME
MI4490210002Medicare NSC