Provider Demographics
NPI:1528094489
Name:TAWAS FOOT CLINIC P.C.
Entity type:Organization
Organization Name:TAWAS FOOT CLINIC P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-362-6558
Mailing Address - Street 1:PO BOX 178
Mailing Address - Street 2:
Mailing Address - City:TAWAS CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48764-0178
Mailing Address - Country:US
Mailing Address - Phone:989-362-6558
Mailing Address - Fax:989-365-7168
Practice Address - Street 1:166 M 55
Practice Address - Street 2:
Practice Address - City:TAWAS CITY
Practice Address - State:MI
Practice Address - Zip Code:48763
Practice Address - Country:US
Practice Address - Phone:989-362-6558
Practice Address - Fax:989-362-7168
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-23
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901001133213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4310389Medicaid
MI480026004OtherPALMETTO GBA-RR MEDICARE
MI71020000C51005OtherBLUE CROSS BLUE SHIELD
MI71020000C51005OtherBLUE CROSS BLUE SHIELD
MI4310389Medicaid
MIT34277Medicare UPIN