Basic Information
| Provider Information | |||||||||
| NPI: | 1588649230 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTERS FOR FOOT & ANKLE CARE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4700 SMITH RD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452122787 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5136196885 | ||||||||
| FaxNumber: | 5135336001 | ||||||||
| Practice Location | |||||||||
| Address1: | 3120 BURNET AVE | ||||||||
| Address2: | SUITE 404 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452293091 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5132212595 | ||||||||
| FaxNumber: | 5138611778 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2005 | ||||||||
| LastUpdateDate: | 02/28/2019 | ||||||||
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| AuthorizedOfficialLastName: | MINNIE | ||||||||
| AuthorizedOfficialFirstName: | NICKOLAS | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5138448585 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DPM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 2937933 | 05 | OH | MEDICAID |