Provider Demographics
NPI:1063459675
Name:SON SHINE FOOT AND ANKLE CENTER INC
Entity Type:Organization
Organization Name:SON SHINE FOOT AND ANKLE CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:DERRICO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:772-380-0900
Mailing Address - Street 1:PO BOX 8210
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34985-8210
Mailing Address - Country:US
Mailing Address - Phone:772-380-0900
Mailing Address - Fax:772-380-0901
Practice Address - Street 1:1405 SE GOLDTREE DR
Practice Address - Street 2:SUITE B
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7563
Practice Address - Country:US
Practice Address - Phone:772-380-0900
Practice Address - Fax:772-380-0901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO2649213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU73607Medicare UPIN
FLK1969AMedicare PIN
FL3894500001Medicare NSC
FLE1962BMedicare PIN