Healthcare Provider Details

I. General information

NPI: 1780763870
Provider Name (Legal Business Name): KALAMAZOO FOOT SURGERY, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 04/17/2023
Certification Date: 04/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1212 S PARK ST
KALAMAZOO MI
49001-5600
US

IV. Provider business mailing address

1212 S PARK ST
KALAMAZOO MI
49001-5600
US

V. Phone/Fax

Practice location:
  • Phone: 269-344-0874
  • Fax: 269-344-7256
Mailing address:
  • Phone: 269-344-0874
  • Fax: 269-344-7256

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: RICK WILLIAM TILLER
Title or Position: DOCTOR
Credential: D.P.M.
Phone: 269-344-0874