Basic Information
Provider Information | |||||||||
NPI: | 1174657977 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | THE FOOT AND ANKLE CLINIC LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 80690 | ||||||||
Address2: |   | ||||||||
City: | CANTON | ||||||||
State: | OH | ||||||||
PostalCode: | 447080690 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3308335692 | ||||||||
FaxNumber: | 3308336085 | ||||||||
Practice Location | |||||||||
Address1: | 1730 W 25TH ST | ||||||||
Address2: | 2E | ||||||||
City: | CLEVELAND | ||||||||
State: | OH | ||||||||
PostalCode: | 441133108 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2162272194 | ||||||||
FaxNumber: | 2162272196 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/15/2007 | ||||||||
LastUpdateDate: | 01/24/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KOVACH | ||||||||
AuthorizedOfficialFirstName: | KRISTINA | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 2162272194 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | DPM | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 36002928 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |   |
ID Information
ID | Type | State | Issuer | Description | 2035158 | 05 | OH |   | MEDICAID |