Healthcare Provider Details

I. General information

NPI: 1760529705
Provider Name (Legal Business Name): BLUE WATER PODIATRY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 10/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

828 10TH AVE
PORT HURON MI
48060-3640
US

IV. Provider business mailing address

5303 SHOREWOOD DR
FORT GRATIOT MI
48059-3137
US

V. Phone/Fax

Practice location:
  • Phone: 810-982-4240
  • Fax: 810-982-2479
Mailing address:
  • Phone: 810-385-2053
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number59000955
License Number StateMI

VIII. Authorized Official

Name: DR. THOMAS K ERNST
Title or Position: OWNER
Credential: DPM
Phone: 810-982-4240