Basic Information
Provider Information | |||||||||
NPI: | 1144617556 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PODIATRY INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3733 PARK EAST DR | ||||||||
Address2: | SUITE 240 | ||||||||
City: | BEACHWOOD | ||||||||
State: | OH | ||||||||
PostalCode: | 441224337 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2162451290 | ||||||||
FaxNumber: | 8665714884 | ||||||||
Practice Location | |||||||||
Address1: | 6563 WILSON MILLS RD | ||||||||
Address2: | SUITE 101 | ||||||||
City: | MAYFIELD VILLAGE | ||||||||
State: | OH | ||||||||
PostalCode: | 441433409 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2162451290 | ||||||||
FaxNumber: | 8665714884 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/23/2015 | ||||||||
LastUpdateDate: | 04/23/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PARKS | ||||||||
AuthorizedOfficialFirstName: | TIFFANY | ||||||||
AuthorizedOfficialMiddleName: | DODDS | ||||||||
AuthorizedOfficialTitleorPosition: | AR SUPERVISOR | ||||||||
AuthorizedOfficialTelephone: | 2166724330 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | CPC, CPB | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |   | 213ES0103X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 332B00000X |   |   | Y |   | Suppliers | Durable Medical Equipment & Medical Supplies |   |
No ID Information.