GRAND LAKE PODIATRY INC NPI 1184896383

NPI Information

  • NPI: 1184896383
  • Provider Name: GRAND LAKE PODIATRY INC
  • Classification: Podiatrist - 213ES0103X
  • Specialization: Foot & Ankle Surgery
  • Entity Type: Organization
  • CLIA Number: 36D2140048
  • Address: 3772 US RT 68 S
    BELLEFONTAINE, OH
    ZIP 43311
  • Phone: (937) 599-3668

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NPI Details

GRAND LAKE PODIATRY INC is a foot and ankle surgery podiatrist in Bellefontaine, OH. GRAND LAKE PODIATRY INC NPI is 1184896383. The provider is registered as an organization entity type and is a single specialty group.

The provider's business location address is:

3772 US RT 68 S
BELLEFONTAINE, OH
ZIP 43311-311
Phone: (937) 599-3668
Fax: (937) 599-4852

The provider's authorized official is Mary Katherine Benjamin-swonger .
The authorized official title is Podiatrist/owner-president and has the following contact phone number (419) 586-7874.

The CLIA number assigned to this NPI record is 36D2140048 - physician office with a certificate type of Certificate of Waiver.

The enumeration date for this NPI number is 3/27/2008 and was last updated on 6/9/2011.

Taxonomy Codes

The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:

No. Taxonomy Code Taxonomy Clasification Taxonomy Specialization License Number License State Primary
1213ES0103XPodiatristFoot & Ankle Surgery36 002772OHIOYes

Other Identifiers

The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.

No. Other Provider Identifier Other Provider Identifier Type Other Provider Identifier State Other Provider Identifier Issuer
11153470008MEDICARE NSC
29285765MEDICARE PINOHIO
32544858MEDICAIDOHIO
4CG6681MEDICARE PIN

What is NPI?

NPI stands for National Provider Identifier. The NPI is a 10-digit identification number that is completely unique. The NPI number by itself does not contain any identifiable information such as a provider’s speciality or location. The NPI is assigned to individuals or organizacions for their lifespan and it is independent of key provider information type updates like a change of practices, location or speciality.

This page was last updated on: 11/21/2025

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