Provider Demographics
NPI:1194906479
Name:AFFILIATED PODIATRIST, P.C.
Entity type:Organization
Organization Name:AFFILIATED PODIATRIST, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:
Authorized Official - First Name:ARTHUR
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:KELLERT
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:734-721-0561
Mailing Address - Street 1:35519 E MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:MI
Mailing Address - Zip Code:48184-1682
Mailing Address - Country:US
Mailing Address - Phone:734-721-0561
Mailing Address - Fax:734-721-7583
Practice Address - Street 1:35519 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:MI
Practice Address - Zip Code:48184-1682
Practice Address - Country:US
Practice Address - Phone:734-721-0561
Practice Address - Fax:734-721-7583
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-15
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAK000685213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1074377Medicaid
MI0525060001Medicare NSC
MI0P54690Medicare PIN
MIT97251Medicare UPIN