Basic Information
| Provider Information | |||||||||
| NPI: | 1053395053 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTERS FOR FOOT & ANKLE CARE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25 MERCHANT ST STE 220 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452463740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135331199 | ||||||||
| FaxNumber: | 5136459827 | ||||||||
| Practice Location | |||||||||
| Address1: | 8621 WINTON ROAD | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135212300 | ||||||||
| FaxNumber: | 5135218300 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2005 | ||||||||
| LastUpdateDate: | 07/19/2019 | ||||||||
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| AuthorizedOfficialLastName: | MINNIE | ||||||||
| AuthorizedOfficialFirstName: | NICKOLAS | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5138448585 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DPM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 2937899 | 05 | OH | MEDICAID |