Healthcare Provider Details

I. General information

NPI: 1982728200
Provider Name (Legal Business Name): PODIATRIC MEDICAL ASSOCIATES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 12/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6289 CENTRAL AVE
PORTAGE IN
46368-3725
US

IV. Provider business mailing address

6289 CENTRAL AVE
PORTAGE IN
46368-3725
US

V. Phone/Fax

Practice location:
  • Phone: 219-763-2008
  • Fax: 219-762-2291
Mailing address:
  • Phone: 219-763-2008
  • Fax: 219-762-2291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: DR. STEPHEN K GRANDFIELD
Title or Position: PRESIDENT
Credential: DPM
Phone: 219-763-2008