Basic Information
| Provider Information | |||||||||
| NPI: | 1508032970 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAMILY PODIATRY CARE, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13876 QUEENS BLVD FL 1 | ||||||||
| Address2: | |||||||||
| City: | BRIARWOOD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114352930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188506345 | ||||||||
| FaxNumber: | 7185594895 | ||||||||
| Practice Location | |||||||||
| Address1: | 1029 BELLMORE RD | ||||||||
| Address2: | |||||||||
| City: | N BELLMORE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117103718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166794636 | ||||||||
| FaxNumber: | 5166798239 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2008 | ||||||||
| LastUpdateDate: | 12/23/2008 | ||||||||
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| AuthorizedOfficialLastName: | GEORGE | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2128768590 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 005780 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 02176718 | 05 | NY | MEDICAID | BA7272292 | 01 | NY | DEA | OTHER |