Provider Demographics
NPI:1649467549
Name:GREAT LAKES PODIATRY CENTER, INC
Entity type:Organization
Organization Name:GREAT LAKES PODIATRY CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINKO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:440-937-5400
Mailing Address - Street 1:1502 LEAR INDUSTRIAL PKWY
Mailing Address - Street 2:SUITE 1A
Mailing Address - City:AVON
Mailing Address - State:OH
Mailing Address - Zip Code:44011-1379
Mailing Address - Country:US
Mailing Address - Phone:440-937-5400
Mailing Address - Fax:440-937-5533
Practice Address - Street 1:1502 LEAR INDUSTRIAL PKWY
Practice Address - Street 2:SUITE 1A
Practice Address - City:AVON
Practice Address - State:OH
Practice Address - Zip Code:44011-1379
Practice Address - Country:US
Practice Address - Phone:440-937-5400
Practice Address - Fax:440-937-5533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-25
Last Update Date:2009-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0H 3122213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4673090001Medicare NSC