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General NPI Number Information
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NPI Number | 1669472270
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Entity Type | Organization
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Legal Business Name | GREAT LAKES ORTHOPEDICS & SPORTS MEDICINE, PC
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Dates
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Enumeration Date | 07/26/2005
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Last Update Date | 03/17/2018
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Provider Practice Location Address
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Address Line | 9615 KEILMAN ST
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City | SAINT JOHN
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State | IN
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Zip | 46373-9406
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Country | US
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Telephone | 219-365-0220
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Fax | 219-365-0226
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Provider Business Mailing Address
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Address Line | 9615 KEILMAN ST
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City | SAINT JOHN
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State | IN
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Zip | 46373-9406
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Country | US
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Telephone | 219-365-0220
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Fax | 219-365-0226
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Authorized Official
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Title or Position | PRESIDENT/CEO
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Name | KEITH R. PITCHFORD
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Credential | DO
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Telephone | 219-365-0220
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213ES0103X
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Taxonomy Name | Foot & Ankle Surgery Podiatrist
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License Number | 07001187A
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | 02002102
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License Number State | IN
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