=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225323579
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SORE FEET PODIATRY PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2011
-----------------------------------------------------
Last Update Date | 06/15/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 32432 WOODWARD AVE
-----------------------------------------------------
City | ROYAL OAK
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48073-0947
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-274-7047
-----------------------------------------------------
Fax | 313-274-7032
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 32432 WOODWARD AVE
-----------------------------------------------------
City | ROYAL OAK
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48073-0947
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-274-7047
-----------------------------------------------------
Fax | 313-274-7032
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. RANDY HARVEY BERNSTEIN
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 313-274-7047
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | RB001223
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------