=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508905985
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GEORGETOWN PODIATRIC SURGEONS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3058 METROPOLITAN PKWY STE 206
-----------------------------------------------------
City | STERLING HEIGHTS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48310-3680
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-977-7200
-----------------------------------------------------
Fax | 586-977-7291
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3058 METROPOLITAN PKWY STE 206
-----------------------------------------------------
City | STERLING HEIGHTS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48310-3680
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-977-7200
-----------------------------------------------------
Fax | 586-977-7291
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. LAWRENCE A YOUNG
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 586-977-7200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | 5901000652
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------