MEDICARE: MALA PODIATRIC SERVICES,LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213EP1101X	Primary Podiatric Medicine Podiatrist	400101	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1134126386
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MALA PODIATRIC SERVICES,LLC

Provider Business Mailing Address
First Line	:	4595 NATHAN W
Second Line	:
City	:	STERLING HEIGHTS
State	:	MI
Zip	:	48310-2658
Country	:	US
Telephone Number	:	586-759-4170
Fax Number	:	586-759-0150

Provider Business Practice Location Address
First Line	:	4595 NATHAN W
Second Line	:
City	:	STERLING HEIGHTS
State	:	MI
Zip	:	48310-2658
Country	:	US
Telephone Number	:	586-759-4170
Fax Number	:	586-759-0150

Authorized Official
Title or Position	:	OWNER
Name	:	OLEH ROMAN LAWRIN
Credential	:	DPM
Telephone Number	:	586-759-4170

Provider Enumeration Date	:	07/01/2005
Last Update Date	:	09/29/2015

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