Basic Information
| Provider Information | |||||||||
| NPI: | 1417620170 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GREAT LAKES FOOT & ANKLE INSTITUTE PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 32743 23 MILE RD STE 210 | ||||||||
| Address2: | |||||||||
| City: | CHESTERFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480472176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867253444 | ||||||||
| FaxNumber: | 5867250984 | ||||||||
| Practice Location | |||||||||
| Address1: | 32743 23 MILE RD STE 110 | ||||||||
| Address2: | |||||||||
| City: | CHESTERFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480472082 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867253444 | ||||||||
| FaxNumber: | 5867250984 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2021 | ||||||||
| LastUpdateDate: | 07/28/2021 | ||||||||
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| AuthorizedOfficialLastName: | FRASCONE | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5867253444 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GREAT LAKES FOOT & ANKLE INSTITUTE PC | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 07/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0105X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine | 207ZP0101X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology |
No ID Information.