Healthcare Provider Details

I. General information

NPI: 1295825099
Provider Name (Legal Business Name): SUMMIT PODIATRY GROUP PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 10/21/2020
Certification Date: 10/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2797 SPRING ARBOR ROAD SUITE A
JACKSON MI
49203
US

IV. Provider business mailing address

2797 SPRING ARBOR ROAD SUITE A
JACKSON MI
49203
US

V. Phone/Fax

Practice location:
  • Phone: 517-784-0900
  • Fax: 517-784-7835
Mailing address:
  • Phone: 517-784-0900
  • Fax: 517-784-7835

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: DR. KRISTI J LEDBETTER
Title or Position: VICE PRESIDENT
Credential: DPM
Phone: 517-784-0900