1154344422 NPI number — FIRST STATE FOOT & ANKLE, LLC

Table of content: (NPI 1154344422)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154344422 NPI number — FIRST STATE FOOT & ANKLE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FIRST STATE FOOT & ANKLE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154344422
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/07/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4512 KIRKWOOD HIGHWAY SUITE 203
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILMINGTON
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19808
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-984-0257
Provider Business Mailing Address Fax Number:
302-984-0258

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4512 KIRKWOOD HIGHWAY SUITE 203
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILMINGTON
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19808
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-984-0257
Provider Business Practice Location Address Fax Number:
302-984-0258
Provider Enumeration Date:
07/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HOLVECK
Authorized Official First Name:
HEATHER
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
302-984-0257

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  E1-0000143 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2245524000 . This is a "AMERIHEALTH/ KEYSTONE #" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 7752539 . This is a "AETNA GROUP #" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 1000027213 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0001047917 . This is a "DELAWARE PHYSICIANS INC." identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".




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