Healthcare Provider Details

I. General information

NPI: 1558553628
Provider Name (Legal Business Name): DIABETIC FOOT PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2007
Last Update Date: 08/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1281 E SHERMAN BLVD
MUSKEGON MI
49444-1846
US

IV. Provider business mailing address

1281 E SHERMAN BLVD PO BOX 4344
MUSKEGON MI
49444-1846
US

V. Phone/Fax

Practice location:
  • Phone: 231-733-1511
  • Fax: 231-733-7980
Mailing address:
  • Phone: 231-733-1511
  • Fax: 231-733-7980

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberSH001528
License Number StateMI

VIII. Authorized Official

Name: DR. SUSAN ELAINE HOLIBAUGH
Title or Position: PRESIDENT
Credential: DPM
Phone: 231-733-1511