Provider Demographics
NPI:1609129881
Name:PINOLE PODIATRY GROUP INC
Entity type:Organization
Organization Name:PINOLE PODIATRY GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:GRIMES
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:510-724-1530
Mailing Address - Street 1:2150 APPIAN WAY STE 206
Mailing Address - Street 2:
Mailing Address - City:PINOLE
Mailing Address - State:CA
Mailing Address - Zip Code:94564-2520
Mailing Address - Country:US
Mailing Address - Phone:510-724-1530
Mailing Address - Fax:
Practice Address - Street 1:2150 APPIAN WAY STE 206
Practice Address - Street 2:
Practice Address - City:PINOLE
Practice Address - State:CA
Practice Address - Zip Code:94564-2520
Practice Address - Country:US
Practice Address - Phone:510-724-1530
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-25
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4413213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4730330001Medicare NSC