Provider Demographics
NPI:1962425934
Name:GARY P. CERESNIE, D.P.M., P.C.
Entity type:Organization
Organization Name:GARY P. CERESNIE, D.P.M., P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:P
Authorized Official - Last Name:CERESNIE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:810-225-3338
Mailing Address - Street 1:7990 GRAND RIVER RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48114-7326
Mailing Address - Country:US
Mailing Address - Phone:810-225-3338
Mailing Address - Fax:810-225-3668
Practice Address - Street 1:7990 GRAND RIVER RD
Practice Address - Street 2:SUITE D
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48114-7326
Practice Address - Country:US
Practice Address - Phone:810-225-3338
Practice Address - Fax:810-225-3668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901001780213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3313564Medicaid
MI0P33660Medicare PIN
MI4739840001Medicare NSC
MI3313564Medicaid