MEDICARE: MOBILE PODIATRY SERVICES, 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
1	213ES0131X	Foot Surgery Podiatrist	5901001714	MI

General Provider Information

NPI Number	:	1720442056
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOBILE PODIATRY SERVICES, PC

Provider Business Mailing Address
First Line	:	12786 LASALLE LN
Second Line	:
City	:	HUNTINGTON WOODS
State	:	MI
Zip	:	48070-1020
Country	:	US
Telephone Number	:	773-263-8540
Fax Number	:	773-866-1733

Provider Business Practice Location Address
First Line	:	12786 LASALLE LN
Second Line	:
City	:	HUNTINGTON WOODS
State	:	MI
Zip	:	48070-1020
Country	:	US
Telephone Number	:	773-263-8540
Fax Number	:	773-866-1733

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. THOMAS D PAHOLAK
Credential	:	DPM
Telephone Number	:	773-263-8540

Provider Enumeration Date	:	04/12/2016
Last Update Date	:	04/12/2016

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