Healthcare Provider Details

I. General information

NPI: 1538331525
Provider Name (Legal Business Name): GRAND LAKE PODIATRY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2008
Last Update Date: 04/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

812 REDSKIN TRL STE B
WAPAKONETA OH
45895-8545
US

IV. Provider business mailing address

1222 IRMSCHER BLVD
CELINA OH
45822-8305
US

V. Phone/Fax

Practice location:
  • Phone: 419-586-7874
  • Fax: 419-586-2776
Mailing address:
  • Phone: 419-586-7874
  • Fax: 416-586-2776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number36 002772
License Number StateOH

VIII. Authorized Official

Name: DR. MARY KATHERINE BENJAMIN-SWONGER
Title or Position: PODIATRIST/OWNER-PRESIDENT
Credential: DPM
Phone: 419-586-7874