Provider Demographics
NPI:1962526624
Name:LONG LAKE PODIATRY PC
Entity type:Organization
Organization Name:LONG LAKE PODIATRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LEAH
Authorized Official - Middle Name:LAINE
Authorized Official - Last Name:MATHESON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:248-528-0709
Mailing Address - Street 1:2914 E LONG LAKE RD
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48085-3780
Mailing Address - Country:US
Mailing Address - Phone:248-528-0709
Mailing Address - Fax:248-528-1807
Practice Address - Street 1:2914 E LONG LAKE RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48085-3780
Practice Address - Country:US
Practice Address - Phone:248-528-0709
Practice Address - Fax:248-528-1807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901001005213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5631470OtherBLUE CROSS BLUE SHIELD
MI89594BOtherHAP
MI1634294Medicaid
MI0005335144OtherAETNA
MIOP21910Medicare ID - Type Unspecified
MI89594BOtherHAP