Provider Demographics
NPI:1457385841
Name:LARRY WEISS DPM PC
Entity Type:Organization
Organization Name:LARRY WEISS DPM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING AGENT
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:HILLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-569-5960
Mailing Address - Street 1:17421 GREENFIELD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235
Mailing Address - Country:US
Mailing Address - Phone:313-273-7091
Mailing Address - Fax:313-273-7694
Practice Address - Street 1:17421 GREENFIELD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235
Practice Address - Country:US
Practice Address - Phone:313-273-7091
Practice Address - Fax:313-273-7694
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901000807213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1485013Medicaid
MIT34409Medicare UPIN
MI0M22500Medicare PIN
MI1485013Medicaid