1568783553 NPI number — ADVANCED FOOT AND ANKLE ASSOCIATES PLLC

Table of content: (NPI 1568783553)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568783553 NPI number — ADVANCED FOOT AND ANKLE ASSOCIATES PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED FOOT AND ANKLE ASSOCIATES PLLC
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:
1568783553
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/28/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6312 AZLE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76135-2442
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-238-8400
Provider Business Mailing Address Fax Number:
817-238-8401

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6312 AZLE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76135-2442
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-238-8400
Provider Business Practice Location Address Fax Number:
817-238-8401
Provider Enumeration Date:
06/14/2010

Additional Information

Authorized Official

Authorized Official Last Name:
PENDLETON
Authorized Official First Name:
RUSSELL
Authorized Official Middle Name:
OLIN
Authorized Official Title or Position:
OWNER/PHYSICIAN
Authorized Official Telephone Number:
817-238-8400

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  1916 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0029WA . This is a "BCBS TX" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 218408702 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 218408703 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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