Healthcare Provider Details

I. General information

NPI: 1194906479
Provider Name (Legal Business Name): AFFILIATED PODIATRIST, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2007
Last Update Date: 05/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35519 E MICHIGAN AVE
WAYNE MI
48184-1682
US

IV. Provider business mailing address

35519 E MICHIGAN AVE
WAYNE MI
48184-1682
US

V. Phone/Fax

Practice location:
  • Phone: 734-721-0561
  • Fax: 734-721-7583
Mailing address:
  • Phone: 734-721-0561
  • Fax: 734-721-7583

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberAK000685
License Number StateMI

VIII. Authorized Official

Name: ARTHUR BRUCE KELLERT
Title or Position: PODIATRIST
Credential: D.P.M.
Phone: 734-721-0561