MEDICARE: ORCHARD LAKE FOOTCARE SPECIALISTS, P.L.L.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213ES0103X	Foot & Ankle Surgery Podiatrist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	480F37410	OTHER	MI	BCBSMI

General Provider Information

NPI Number	:	1649240375
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ORCHARD LAKE FOOTCARE SPECIALISTS, P.L.L.C.

Provider Business Mailing Address
First Line	:	3206 ORCHARD LAKE RD
Second Line	:
City	:	ORCHARD LAKE
State	:	MI
Zip	:	48324-1633
Country	:	US
Telephone Number	:	248-682-6662
Fax Number	:	248-682-2850

Provider Business Practice Location Address
First Line	:	3206 ORCHARD LAKE RD
Second Line	:
City	:	ORCHARD LAKE
State	:	MI
Zip	:	48324-1633
Country	:	US
Telephone Number	:	248-682-6662
Fax Number	:	248-682-2850

Authorized Official
Title or Position	:	OWNER
Name	:	DR. GERALD GOLD
Credential	:	D.P.M.
Telephone Number	:	248-682-6662

Provider Enumeration Date	:	01/25/2006
Last Update Date	:	01/17/2008

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