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General NPI Number Information
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NPI Number | 1558553628
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Entity Type | Organization
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Legal Business Name | DIABETIC FOOT PLLC
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Dates
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Enumeration Date | 08/13/2007
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Last Update Date | 08/13/2007
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Provider Practice Location Address
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Address Line | 1281 E SHERMAN BLVD
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City | MUSKEGON
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State | MI
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Zip | 49444-1846
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Country | US
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Telephone | 231-733-1511
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Fax | 231-733-7980
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Provider Business Mailing Address
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Address Line | 1281 E SHERMAN BLVD PO BOX 4344
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City | MUSKEGON
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State | MI
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Zip | 49444-1846
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Country | US
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Telephone | 231-733-1511
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Fax | 231-733-7980
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. SUSAN ELAINE HOLIBAUGH
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Credential | DPM
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Telephone | 231-733-1511
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213E00000X
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Taxonomy Name | Podiatrist
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License Number | SH001528
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License Number State | MI
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