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NPI Code Detail

MEDICARE: GREAT LAKES ORTHOPEDICS & SPORTS MEDICINE, PC

MEDICARE: GREAT LAKES ORTHOPEDICS & SPORTS MEDICINE, PC
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
1213ES0103XFoot & Ankle Surgery Podiatrist07001187AIN
2207X00000XOrthopaedic Surgery Physician02002102IN

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1DC2442OTHERINRAILROAD MEDICARE

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
290001186OTHERILBC/BS IL

General Provider Information

NPI Number : 1669472270
Entity Type Code : Organization
Provider Name (Legal Business Name) : GREAT LAKES ORTHOPEDICS & SPORTS MEDICINE, PC
Provider Business Mailing Address
First Line : 9615 KEILMAN ST
Second Line :
City : SAINT JOHN
State : IN
Zip : 46373-9406
Country : US
Telephone Number : 219-365-0220
Fax Number : 219-365-0226
Provider Business Practice Location Address
First Line : 9615 KEILMAN ST
Second Line :
City : SAINT JOHN
State : IN
Zip : 46373-9406
Country : US
Telephone Number : 219-365-0220
Fax Number : 219-365-0226
Authorized Official
Title or Position : PRESIDENT/CEO
Name : KEITH R. PITCHFORD
Credential : DO
Telephone Number : 219-365-0220
Provider Enumeration Date : 07/26/2005
Last Update Date : 03/17/2018

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Directions to “GREAT LAKES ORTHOPEDICS & SPORTS MEDICINE, PC ” Practice Location

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