1104861475 NPI number — HEALTHDRIVE PODIATRY GROUP, PA

Table of content: (NPI 1104861475)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104861475 NPI number — HEALTHDRIVE PODIATRY GROUP, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEALTHDRIVE PODIATRY GROUP, PA
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:
6
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:
1104861475
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/02/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 CROSSING BLVD
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
FRAMINGHAM
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01702-5555
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-964-6681
Provider Business Mailing Address Fax Number:
617-630-0141

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4201 FM 1960 RD W
Provider Second Line Business Practice Location Address:
SUITE # 230
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77068-3414
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-537-1599
Provider Business Practice Location Address Fax Number:
281-537-1310
Provider Enumeration Date:
06/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TRBOVICH
Authorized Official First Name:
MICHELE
Authorized Official Middle Name:
LEE
Authorized Official Title or Position:
PRESIDENT/PRACTICE DIRECTOR
Authorized Official Telephone Number:
214-697-0727

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 171674801 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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