Provider Demographics
NPI:1639117039
Name:BIRCH TREE PODIATRY GROUP PC
Entity type:Organization
Organization Name:BIRCH TREE PODIATRY GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:LATHROP
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:231-946-8822
Mailing Address - Street 1:620 WOODMERE AVE
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-3397
Mailing Address - Country:US
Mailing Address - Phone:231-946-8822
Mailing Address - Fax:231-947-0977
Practice Address - Street 1:620 WOODMERE AVE
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-3397
Practice Address - Country:US
Practice Address - Phone:231-946-8822
Practice Address - Fax:231-947-0977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2010-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIDL000642261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1127730001Medicare NSC
MI1639117039Medicare PIN