Healthcare Provider Details

I. General information

NPI: 1801276274
Provider Name (Legal Business Name): WASHTENAW PODIATRY GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2015
Last Update Date: 06/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3145 W CLARK RD SUITE 201
YPSILANTI MI
48197-1120
US

IV. Provider business mailing address

3145 W CLARK RD SUITE 201
YPSILANTI MI
48197-1120
US

V. Phone/Fax

Practice location:
  • Phone: 734-572-1141
  • Fax: 734-572-1142
Mailing address:
  • Phone: 734-572-1141
  • Fax: 734-572-1142

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: MARK J KLEIN
Title or Position: OWNER
Credential: DPM
Phone: 734-572-1141