MEDICARE: BIRCH TREE PODIATRY GROUP PC

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	261QP1100X	Podiatric Clinic/Center	DL000642	MI

General Provider Information

NPI Number	:	1639117039
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BIRCH TREE PODIATRY GROUP PC

Provider Business Mailing Address
First Line	:	620 WOODMERE AVE
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49686-3397
Country	:	US
Telephone Number	:	231-946-8822
Fax Number	:	231-947-0977

Provider Business Practice Location Address
First Line	:	620 WOODMERE AVE
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49686-3397
Country	:	US
Telephone Number	:	231-946-8822
Fax Number	:	231-947-0977

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. DANIEL T LATHROP
Credential	:	DPM
Telephone Number	:	231-946-8822

Provider Enumeration Date	:	06/04/2006
Last Update Date	:	11/29/2010

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