Basic Information
Provider Information
NPI: 1801874383
EntityType: 2
ReplacementNPI:  
OrganizationName: ADVANCED FOOT AND ANKLE SPECIALISTS, LLC
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Mailing Information
Address1: 8808 TYLER BLVD
Address2:  
City: MENTOR
State: OH
PostalCode: 440604361
CountryCode: US
TelephoneNumber: 4407776017
FaxNumber:  
Practice Location
Address1: 8808 TYLER BLVD
Address2:  
City: MENTOR
State: OH
PostalCode: 440604361
CountryCode: US
TelephoneNumber: 4402556222
FaxNumber: 4402554321
Other Information
ProviderEnumerationDate: 01/05/2006
LastUpdateDate: 12/29/2009
NPIDeactivationReasonCode:  
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AuthorizedOfficialLastName: BILANT
AuthorizedOfficialFirstName: KEVIN
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AuthorizedOfficialTitleorPosition: PRESIDENT
AuthorizedOfficialTelephone: 4402556222
IsSoleProprietor:  
IsOrganizationSubpart: N
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AuthorizedOfficialCredential: DPM
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
332B00000X OHN SuppliersDurable Medical Equipment & Medical Supplies 
213E00000X  Y193400000X SINGLE SPECIALTY GROUPPodiatric Medicine & Surgery Service ProvidersPodiatrist 

ID Information
IDTypeStateIssuerDescription
233904405OH MEDICAID


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