Provider Demographics
NPI:1982728200
Name:PODIATRIC MEDICAL ASSOCIATES PC
Entity Type:Organization
Organization Name:PODIATRIC MEDICAL ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:K
Authorized Official - Last Name:GRANDFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:219-763-2008
Mailing Address - Street 1:6289 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-3725
Mailing Address - Country:US
Mailing Address - Phone:219-763-2008
Mailing Address - Fax:219-762-2291
Practice Address - Street 1:6289 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-3725
Practice Address - Country:US
Practice Address - Phone:219-763-2008
Practice Address - Fax:219-762-2291
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200326020Medicaid
IN492470OtherRR MEDICARE
IN100907960Medicaid
IN653120DMedicare PIN
IN653120AMedicare PIN
IN492470OtherRR MEDICARE
IN653120Medicare ID - Type Unspecified
IN200326020Medicaid