Provider Demographics
NPI:1871778647
Name:SAGINAW VALLEY FOOT & ANKLE CENTER
Entity type:Organization
Organization Name:SAGINAW VALLEY FOOT & ANKLE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:TESORO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:989-790-4662
Mailing Address - Street 1:5400 MACKINAW
Mailing Address - Street 2:SUITE 2100
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48604-9549
Mailing Address - Country:US
Mailing Address - Phone:989-790-4662
Mailing Address - Fax:989-790-7680
Practice Address - Street 1:5400 MACKINAW
Practice Address - Street 2:SUITE 2100
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48604-9549
Practice Address - Country:US
Practice Address - Phone:989-790-4662
Practice Address - Fax:989-790-7680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-29
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIDT001450213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3173006Medicaid
MI4857311150OtherBLUE CROSS
MI480019411OtherMEDICARE RAILROAD
MI1198630001OtherMEDICARE SUPPLIER ID
MI11290415OtherCAQH
MI480019411OtherMEDICARE RAILROAD
MIOM12060Medicare Oscar/Certification
MI1198630001Medicare NSC