=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316191679
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GFC OF SOUTHEASTERN MICHIGAN, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/12/2008
-----------------------------------------------------
Last Update Date | 12/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4160 JOHN R ST STE 1011
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48201-2017
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-833-3090
-----------------------------------------------------
Fax | 313-833-7843
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4160 JOHN R ST STE 111
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48201-2021
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-833-3090
-----------------------------------------------------
Fax | 313-833-7843
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | DR. MANISHA MEHTA
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 313-833-3090
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | 5901002275
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------