Basic Information
| Provider Information | |||||||||
| NPI: | 1063445237 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GREAT LAKES FOOT & ANKLE INSTITUTE PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 32743 23 MILE RD | ||||||||
| Address2: | STE 210 | ||||||||
| City: | CHESTERFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480471985 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867253444 | ||||||||
| FaxNumber: | 5867250984 | ||||||||
| Practice Location | |||||||||
| Address1: | 32743 23 MILE RD | ||||||||
| Address2: | STE 210 | ||||||||
| City: | CHESTERFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480471985 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867253444 | ||||||||
| FaxNumber: | 5867250984 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2006 | ||||||||
| LastUpdateDate: | 06/16/2021 | ||||||||
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| AuthorizedOfficialLastName: | FRASCONE | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | THOMAS | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5867253444 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | D.P.M. | ||||||||
| NPICertificationDate: | 01/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
No ID Information.