Provider Demographics
NPI:1548450414
Name:GREAT LAKES FOOT & ANKLE SPECIALIST, PLLC
Entity type:Organization
Organization Name:GREAT LAKES FOOT & ANKLE SPECIALIST, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/ OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:A
Authorized Official - Last Name:SZCZEPANSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:231-935-8800
Mailing Address - Street 1:10161 E PICKWICK CT STE E
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-5239
Mailing Address - Country:US
Mailing Address - Phone:231-935-8800
Mailing Address - Fax:231-935-8801
Practice Address - Street 1:10161 E PICKWICK CT STE E
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-5239
Practice Address - Country:US
Practice Address - Phone:231-935-8800
Practice Address - Fax:231-935-8801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-27
Last Update Date:2023-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901001932261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
5960680001Medicare NSC