Healthcare Provider Details

I. General information

NPI: 1720442056
Provider Name (Legal Business Name): MOBILE PODIATRY SERVICES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2016
Last Update Date: 04/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12786 LASALLE LN
HUNTINGTON WOODS MI
48070-1020
US

IV. Provider business mailing address

12786 LASALLE LN
HUNTINGTON WOODS MI
48070-1020
US

V. Phone/Fax

Practice location:
  • Phone: 773-263-8540
  • Fax: 773-866-1733
Mailing address:
  • Phone: 773-263-8540
  • Fax: 773-866-1733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number5901001714
License Number StateMI

VIII. Authorized Official

Name: DR. THOMAS D PAHOLAK
Title or Position: PRESIDENT
Credential: DPM
Phone: 773-263-8540