Healthcare Provider Details

I. General information

NPI: 1417155508
Provider Name (Legal Business Name): FOOT & ANKLE SPECIALISTS OF WEST MICHIGAN P L L C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2007
Last Update Date: 06/22/2023
Certification Date: 06/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1195 WILSON NW
GRAND RAPIDS MI
49534-6404
US

IV. Provider business mailing address

2144 E PARIS AVE SE STE 100
GRAND RAPIDS MI
49546-6117
US

V. Phone/Fax

Practice location:
  • Phone: 616-453-8277
  • Fax: 616-453-2002
Mailing address:
  • Phone: 616-281-0666
  • Fax: 616-281-0752

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberOM71140
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberWD000997
License Number StateMI

VIII. Authorized Official

Name: LOWELL WEIL JR.
Title or Position: EXECUTIVE CHAIRMAN
Credential: DPM
Phone: 847-390-7666