Basic Information
| Provider Information | |||||||||
| NPI: | 1467736207 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ADVANCE ANKLE, FOOT AND PAIN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1084 MAIN AVE | ||||||||
| Address2: | |||||||||
| City: | CLIFTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070112330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9734734040 | ||||||||
| FaxNumber: | 9734722451 | ||||||||
| Practice Location | |||||||||
| Address1: | 1084 MAIN AVE | ||||||||
| Address2: | |||||||||
| City: | CLIFTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070112330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9734734040 | ||||||||
| FaxNumber: | 9734722451 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2011 | ||||||||
| LastUpdateDate: | 09/28/2011 | ||||||||
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| AuthorizedOfficialLastName: | BEG | ||||||||
| AuthorizedOfficialFirstName: | MIRZA | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEMBERS/MANAGERS | ||||||||
| AuthorizedOfficialTelephone: | 9734734040 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111NN0400X | NJ | N | 193200000X MULTI-SPECIALTY GROUP | Chiropractic Providers | Chiropractor | Neurology | 174400000X | NJ | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist | 208VP0000X | NJ | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | 305R00000X | NJ | N | Managed Care Organizations | Preferred Provider Organization | 2084N0400X | NJ | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
No ID Information.