Basic Information
| Provider Information | |||||||||
| NPI: | 1871980284 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PODIATRY INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3733 PARK EAST DR | ||||||||
| Address2: | SUITE 240 | ||||||||
| City: | BEACHWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441224337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162451290 | ||||||||
| FaxNumber: | 8665714884 | ||||||||
| Practice Location | |||||||||
| Address1: | 9630 RAVENNA RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | TWINSBURG | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440876812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162451290 | ||||||||
| FaxNumber: | 8665714884 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2015 | ||||||||
| LastUpdateDate: | 04/23/2015 | ||||||||
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| AuthorizedOfficialLastName: | PARKS | ||||||||
| AuthorizedOfficialFirstName: | TIFFANY | ||||||||
| AuthorizedOfficialMiddleName: | DODDS | ||||||||
| AuthorizedOfficialTitleorPosition: | AR SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 2166724430 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | CPC, CPB | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | 213ES0103X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.