Provider Demographics
NPI:1720442056
Name:MOBILE PODIATRY SERVICES, PC
Entity Type:Organization
Organization Name:MOBILE PODIATRY SERVICES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:D
Authorized Official - Last Name:PAHOLAK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:773-263-8540
Mailing Address - Street 1:12786 LASALLE LN
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48070-1020
Mailing Address - Country:US
Mailing Address - Phone:773-263-8540
Mailing Address - Fax:773-866-1733
Practice Address - Street 1:12786 LASALLE LN
Practice Address - Street 2:
Practice Address - City:HUNTINGTON WOODS
Practice Address - State:MI
Practice Address - Zip Code:48070-1020
Practice Address - Country:US
Practice Address - Phone:773-263-8540
Practice Address - Fax:773-866-1733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-12
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901001714213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU13617Medicare UPIN