Provider Demographics
NPI:1982714903
Name:LOUIS J GELLER DPM PC
Entity type:Organization
Organization Name:LOUIS J GELLER DPM PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LOUIS
Authorized Official - Middle Name:JEREMY
Authorized Official - Last Name:GELLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-353-0096
Mailing Address - Street 1:25841 PEMBROKE RD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48070-1621
Mailing Address - Country:US
Mailing Address - Phone:248-353-0096
Mailing Address - Fax:248-809-6255
Practice Address - Street 1:28460 SOUTHFIELD RD
Practice Address - Street 2:
Practice Address - City:LATHRUP VILLAGE
Practice Address - State:MI
Practice Address - Zip Code:48076-2820
Practice Address - Country:US
Practice Address - Phone:248-353-0096
Practice Address - Fax:248-809-6255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901001926213E00000X
AZ0524213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4627620001OtherDMERC LICENSE NUMBER
MION53230Medicaid
MI101026OtherGREAT LAKES HEALTH PLAN
MI2430677OtherCIGNA
MI4856352050OtherBLUE CROSS BLUE SHIELD OF MICHIGAN
MI4431259Medicaid
MIU83180Medicare UPIN
MI4627620001Medicare NSC