Provider Demographics
NPI:1063683142
Name:ITHACA PODIATRY ASSOCIATES
Entity Type:Organization
Organization Name:ITHACA PODIATRY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:KADLECIK
Authorized Official - Suffix:X
Authorized Official - Credentials:
Authorized Official - Phone:607-257-7700
Mailing Address - Street 1:2333 N TRIPHAMMER RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-1082
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2333 N TRIPHAMMER RD
Practice Address - Street 2:SUITE 202
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-1082
Practice Address - Country:US
Practice Address - Phone:607-257-7700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-17
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN005805335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02195908Medicaid
4123030001Medicare NSC
NY02195908Medicaid