Provider Demographics
NPI:1154426484
Name:CLINTON FOOT & ANKLE CLINIC PC
Entity type:Organization
Organization Name:CLINTON FOOT & ANKLE CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHERI
Authorized Official - Middle Name:ROSE
Authorized Official - Last Name:DEROCHIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:620-615-6033
Mailing Address - Street 1:PO BOX 0
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MI
Mailing Address - Zip Code:49236-9502
Mailing Address - Country:US
Mailing Address - Phone:517-456-4114
Mailing Address - Fax:517-456-4114
Practice Address - Street 1:1671 W MICHIGAN AVE
Practice Address - Street 2:STE C-1
Practice Address - City:CLINTON
Practice Address - State:MI
Practice Address - Zip Code:49236-8702
Practice Address - Country:US
Practice Address - Phone:517-456-4114
Practice Address - Fax:517-456-4114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901000792213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5067480002OtherDMERC
T34218Medicare UPIN
8465571Medicare ID - Type Unspecified