1750779278 NPI number — FOOTHURT PODIATRY P.C.

Table of content: (NPI 1750779278)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750779278 NPI number — FOOTHURT PODIATRY P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOOTHURT PODIATRY P.C.
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:
1750779278
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/24/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
25 W 45TH ST
Provider Second Line Business Mailing Address:
SUITE 402
Provider Business Mailing Address City Name:
NEW YORK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10036-4902
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
212-704-4310
Provider Business Mailing Address Fax Number:
212-704-4311

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25 W 45TH ST
Provider Second Line Business Practice Location Address:
SUITE 402
Provider Business Practice Location Address City Name:
NEW YORK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10036-4902
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
212-704-4310
Provider Business Practice Location Address Fax Number:
212-704-4311
Provider Enumeration Date:
01/06/2015

Additional Information

Authorized Official

Authorized Official Last Name:
HURT
Authorized Official First Name:
MELVIN
Authorized Official Middle Name:
B.
Authorized Official Title or Position:
CEO/ PRESIDENT
Authorized Official Telephone Number:
631-255-7234

Provider Taxonomy Codes

  • Taxonomy code: 213ES0131X , with the licence number:  N005136 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 01645569 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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