Healthcare Provider Details

I. General information

NPI: 1184618811
Provider Name (Legal Business Name): SCOTT T GRODMAN DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2005
Last Update Date: 05/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9300 PARDEE RD SUITE A
TAYLOR MI
48180-3528
US

IV. Provider business mailing address

9300 PARDEE RD SUITE A
TAYLOR MI
48180-3528
US

V. Phone/Fax

Practice location:
  • Phone: 313-295-1620
  • Fax: 313-295-1622
Mailing address:
  • Phone: 313-295-1620
  • Fax: 313-295-1622

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number5901001478
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: