Basic Information
| Provider Information | |||||||||
| NPI: | 1205816766 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FOOT AND ANKLE SURGICAL ASSOC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 810 | ||||||||
| Address2: | FOOT AND ANKLE SURGICAL ASSOC | ||||||||
| City: | WESTBROOK | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040980810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078541544 | ||||||||
| FaxNumber: | 2078541516 | ||||||||
| Practice Location | |||||||||
| Address1: | 952 POST ROAD | ||||||||
| Address2: | FOOT AND ANKLE SURGICAL ASSOC | ||||||||
| City: | WELLS | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04090 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076469996 | ||||||||
| FaxNumber: | 2076469949 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2006 | ||||||||
| LastUpdateDate: | 07/22/2008 | ||||||||
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| AuthorizedOfficialLastName: | BRAGG | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2078541544 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | POD1039 | ME | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 1659479541 | 01 | ME | IND NPI # | OTHER | 022848 | 01 | ME | ANTHEM MAINE | OTHER | 1205816766 | 01 | ME | GROUP NPI # | OTHER | 431952200 | 05 | ME | MEDICAID | MM9150 | 01 | ME | MEDICARE IND PIN | OTHER |