=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730202482
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RYAN FOOT CLINIC, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/09/2007
-----------------------------------------------------
Last Update Date | 05/06/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25511 VAN DYKE AVE
-----------------------------------------------------
City | CENTER LINE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48015-1834
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-758-5770
-----------------------------------------------------
Fax | 586-758-6134
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25511 VAN DYKE AVE
-----------------------------------------------------
City | CENTER LINE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48015-1834
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-758-5770
-----------------------------------------------------
Fax | 586-758-6134
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER PRESIDENT
-----------------------------------------------------
Name | DR. LAWRENCE STEPHEN BROWN
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 586-758-5770
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------