1275788499 NPI number — CROSSROADS FOOT AND ANKLE PODIATRY PC

Table of content: (NPI 1275788499)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275788499 NPI number — CROSSROADS FOOT AND ANKLE PODIATRY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CROSSROADS FOOT AND ANKLE PODIATRY PC
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:
1275788499
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/01/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 548
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCHESTER
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46975-0548
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-223-6050
Provider Business Mailing Address Fax Number:
574-223-3057

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 E 18TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCHESTER
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46975-2632
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-223-6050
Provider Business Practice Location Address Fax Number:
574-223-3057
Provider Enumeration Date:
12/02/2008

Additional Information

Authorized Official

Authorized Official Last Name:
ROGERS
Authorized Official First Name:
LAURENCE
Authorized Official Middle Name:
C
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
574-223-6050

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0311390001 . This is a "DME" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000091947 . This is a "BCBS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 100173510A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: M100060875 . This is a "MEDICARE PTAN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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