Provider Demographics
NPI:1194760835
Name:PODCARE PC
Entity type:Organization
Organization Name:PODCARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:REPITOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-795-4060
Mailing Address - Street 1:2843 KEELEY CT
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48328
Mailing Address - Country:US
Mailing Address - Phone:586-795-4060
Mailing Address - Fax:
Practice Address - Street 1:8244 METRO PKWY
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48312-2778
Practice Address - Country:US
Practice Address - Phone:586-795-4060
Practice Address - Fax:586-795-9956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901400227213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4835330Medicaid
MI0929530001Medicare NSC
MIT34208Medicare UPIN
MI4835330Medicaid
MI0929530002Medicare NSC
MI0P25770Medicare PIN