=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316041742
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FOOT SPECIALISTS, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11995 E 12 MILE RD STE 202B
-----------------------------------------------------
City | WARREN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48093
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-755-4242
-----------------------------------------------------
Fax | 586-755-6231
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11995 E 12 MILE RD STE 202B
-----------------------------------------------------
City | WARREN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48093
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-755-4242
-----------------------------------------------------
Fax | 586-755-6231
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SEC/TREASURER
-----------------------------------------------------
Name | DR. MARSHALL G SOLOMON
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 586-755-4242
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | MS000671
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | CY000630
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------