Basic Information
| Provider Information | |||||||||
| NPI: | 1093726291 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ACTIVE ANKLE & FOOT CENTER PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2200 | ||||||||
| Address2: | |||||||||
| City: | AMHERST | ||||||||
| State: | NH | ||||||||
| PostalCode: | 030314200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036739411 | ||||||||
| FaxNumber: | 6036739899 | ||||||||
| Practice Location | |||||||||
| Address1: | 251 ELM ST | ||||||||
| Address2: | SUITE #3 | ||||||||
| City: | CLAREMONT | ||||||||
| State: | NH | ||||||||
| PostalCode: | 037434921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6035433668 | ||||||||
| FaxNumber: | 6035439552 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2006 | ||||||||
| LastUpdateDate: | 07/30/2009 | ||||||||
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| AuthorizedOfficialLastName: | GREGORY | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6035433668 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DPM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | ACTI00068638 | 01 | VERMONT BCBS | OTHER | 610830200 | 01 | DEPT OF LABOR | OTHER |