Healthcare Provider Details

I. General information

NPI: 1457789042
Provider Name (Legal Business Name): VISITING PODIATRY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2013
Last Update Date: 10/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2514 S 102ND ST SUITE 160B
WEST ALLIS WI
53227-2142
US

IV. Provider business mailing address

PO BOX 4839
TROY MI
48099-4839
US

V. Phone/Fax

Practice location:
  • Phone: 414-255-0290
  • Fax: 855-422-5184
Mailing address:
  • Phone: 248-824-6600
  • Fax: 248-324-1477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: DR. LYNN A. BEATTY
Title or Position: OWNER
Credential: MD
Phone: 248-824-6000