Provider Demographics
NPI:1063641710
Name:FOOT & ANKLE ASSOCIATES OF THE TRIAD, PA
Entity Type:Organization
Organization Name:FOOT & ANKLE ASSOCIATES OF THE TRIAD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THURMOND
Authorized Official - Middle Name:ERIC
Authorized Official - Last Name:SICELOFF
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:336-774-4021
Mailing Address - Street 1:3641 WESTGATE CENTER CIR
Mailing Address - Street 2:SUITE A
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-2936
Mailing Address - Country:US
Mailing Address - Phone:336-774-4021
Mailing Address - Fax:336-774-4024
Practice Address - Street 1:3641 WESTGATE CENTER CIR
Practice Address - Street 2:SUITE A
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-2936
Practice Address - Country:US
Practice Address - Phone:336-774-4021
Practice Address - Fax:336-774-4024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-02
Last Update Date:2010-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC021WJOtherBCBS
NC5912100Medicaid
NC5912100Medicaid
NC2347378Medicare PIN