1578602330 NPI number — NORTHEAST OHIO FOOT, ANKLE AND WOUND CENTER, INC

Table of content: (NPI 1578602330)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578602330 NPI number — NORTHEAST OHIO FOOT, ANKLE AND WOUND CENTER, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHEAST OHIO FOOT, ANKLE AND WOUND CENTER, INC
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:
1578602330
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/29/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8588 E MARKET ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WARREN
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44484-2339
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-856-4444
Provider Business Mailing Address Fax Number:
330-856-9033

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7264 WARREN SHARON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKFIELD
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44403-9691
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-448-6222
Provider Business Practice Location Address Fax Number:
330-448-6549
Provider Enumeration Date:
02/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LAPOLLA
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
330-448-6222

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  36.002617 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 213ES0103X , with the licence number: SC003389 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 2319128 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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