Provider Demographics
NPI:1750564050
Name:SCOTT GRODMAN DPM PC
Entity type:Organization
Organization Name:SCOTT 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:313-295-1620
Mailing Address - Street 1:9300 PARDEE RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:TAYLOR
Mailing Address - State:MI
Mailing Address - Zip Code:48180-3528
Mailing Address - Country:US
Mailing Address - Phone:313-295-1620
Mailing Address - Fax:313-295-1622
Practice Address - Street 1:9300 PARDEE RD
Practice Address - Street 2:SUITE A
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180-3528
Practice Address - Country:US
Practice Address - Phone:313-295-1620
Practice Address - Fax:313-295-1622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-10
Last Update Date:2017-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI001478332B00000X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2948227Medicaid
MI4858213180OtherBC
MI480H244260OtherBC
MI540H22790OtherBCBS DME
MI2948227Medicaid
MI540H22790OtherBCBS DME
MI0N20760Medicare PIN