Organization
GREAT LAKES ORTHOPEDICS & SPORTS MEDICINE, PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
KEITH R. PITCHFORD DO (PRESIDENT/CEO)
(219) 365-0220
Entity
Organization
Contact information
Practice address
9615 KEILMAN ST, SAINT JOHN, IN 46373-9406
(219) 365-0220
(219) 365-0226
Mailing address
9615 KEILMAN ST, SAINT JOHN, IN 46373-9406
(219) 365-0220
(219) 365-0226
Taxonomy
Speciality
Code
Description
License number
State
207X00000X
Orthopaedic Surgery Physician
Primary
02002102
IN
213ES0103X
Foot & Ankle Surgery Podiatrist
07001187A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
90001186
BC/BS IL
IL
01
—
DC2442
RAILROAD MEDICARE
IN
Enumeration date
07/26/2005
Last updated
03/17/2018
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