Provider Demographics
NPI:1538339676
Name:GRAND MERIDIAN FOOT AND ANKLE SPECIALISTS
Entity type:Organization
Organization Name:GRAND MERIDIAN FOOT AND ANKLE SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:BENDER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:616-784-1595
Mailing Address - Street 1:4310 LEONARD ST NW
Mailing Address - Street 2:SUITE 103
Mailing Address - City:WALKER
Mailing Address - State:MI
Mailing Address - Zip Code:49534-8447
Mailing Address - Country:US
Mailing Address - Phone:616-453-6329
Mailing Address - Fax:616-453-1725
Practice Address - Street 1:721 3 MILE RD NW
Practice Address - Street 2:SUITE 100
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49544-8229
Practice Address - Country:US
Practice Address - Phone:616-784-1595
Practice Address - Fax:616-784-5920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-05
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4854150090OtherBCBSM
MIJB001217OtherSTATE LICENSE
MIES002162OtherSTATE LICENSE
MI0682110001Medicare NSC
MI0N96440Medicare PIN