Healthcare Provider Details

I. General information

NPI: 1639394851
Provider Name (Legal Business Name): KALAMAZOO PODIATRY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2007
Last Update Date: 10/31/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 TURWILL LN
KALAMAZOO MI
49006-5225
US

IV. Provider business mailing address

1773 WOODSIDE TRL NW
GRAND RAPIDS MI
49504-2580
US

V. Phone/Fax

Practice location:
  • Phone: 269-373-1019
  • Fax:
Mailing address:
  • Phone: 616-453-1835
  • Fax: 616-453-1725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberTR000730
License Number StateMI

VIII. Authorized Official

Name: THOMAS D REDMOND
Title or Position: PHYSICIAN
Credential: DPM
Phone: 269-373-1019