Basic Information
Provider Information | |||||||||
NPI: | 1861478547 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CENTERS FOR FOOT & ANKLE CARE, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 25 MERCHANT ST | ||||||||
Address2: | STE. 220 | ||||||||
City: | CINCINNATI | ||||||||
State: | OH | ||||||||
PostalCode: | 452463700 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5135331199 | ||||||||
FaxNumber: | 5136459827 | ||||||||
Practice Location | |||||||||
Address1: | 5300 SOCIALVILLE FOSTER RD | ||||||||
Address2: | STE. 160 | ||||||||
City: | MASON | ||||||||
State: | OH | ||||||||
PostalCode: | 450409429 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5138448585 | ||||||||
FaxNumber: | 5138448769 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/15/2005 | ||||||||
LastUpdateDate: | 07/19/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MINNIE | ||||||||
AuthorizedOfficialFirstName: | NICKOLAS | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 5138448585 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | DPM | ||||||||
NPICertificationDate: |   |
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 | 2128521 | 05 | OH |   | MEDICAID |