Provider Demographics
NPI:1215293550
Name:KEVIN J. PIEBENGA D.P.M. P.C.
Entity type:Organization
Organization Name:KEVIN J. PIEBENGA D.P.M. P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:PIEBENGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:6166-669-7525
Mailing Address - Street 1:3330 CENTRAL BLVD
Mailing Address - Street 2:
Mailing Address - City:HUDSONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49426-1441
Mailing Address - Country:US
Mailing Address - Phone:616-669-7525
Mailing Address - Fax:616-669-9952
Practice Address - Street 1:3330 CENTRAL BOULEVARD
Practice Address - Street 2:
Practice Address - City:HUDSONVILLE
Practice Address - State:MI
Practice Address - Zip Code:49426-4114
Practice Address - Country:US
Practice Address - Phone:616-669-7525
Practice Address - Fax:616-669-9952
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-11
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2693413Medicaid
T96808Medicare UPIN
0423670001Medicare NSC
5705467Medicare PIN