Provider Demographics
NPI:1447467485
Name:DEARBORN PODIATRIC SURGEONS, P.C.
Entity type:Organization
Organization Name:DEARBORN PODIATRIC SURGEONS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:A
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:313-565-8080
Mailing Address - Street 1:22161 W. OUTER DRIVE
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-3901
Mailing Address - Country:US
Mailing Address - Phone:313-565-8080
Mailing Address - Fax:313-565-2417
Practice Address - Street 1:22161 OUTER DR
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-3901
Practice Address - Country:US
Practice Address - Phone:313-565-8080
Practice Address - Fax:313-565-2417
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901000652213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1062616Medicaid
MI5825276OtherBLUE CROSS BLUE SHIELD
MI112003OtherCARE CHOICES
MI5825276OtherBLUE CROSS BLUE SHIELD
MI1062616Medicaid