| Organization Name: | GRAND LAKE PODIATRY INC |
| NPI Number: | 1184896383 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | MARY KATHERINE BENJAMIN-SWONGER (PODIATRIST/OWNER-PRESIDENT) |
| Mailing Address: | 3772 Us Rt 68 S Bellefontaine |
| State: | OH US |
| Postal Code: | 433113311 |
| Phone Number: | 9375993668 |
| Fax Number: | 9375994852 |
| NPI Enumeration Date: | 03/27/2008 |
| NPI Last Update Date: | 06/09/2011 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 213ES0103X |
| License Number: | 36 002772 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | OH |
| Taxonomy Type: | Podiatric Medicine & Surgery Service Providers |
| Taxonomy Classification: | Podiatrist |
| Taxonomy Specialization: | Foot & Ankle Surgery |
| Taxonomy Definition: | |