Provider Demographics
NPI:1073793816
Name:CENTER GROVE FOOT & ANKLE CARE, P.C.
Entity Type:Organization
Organization Name:CENTER GROVE FOOT & ANKLE CARE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:H
Authorized Official - Last Name:RUNKLE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:317-859-2905
Mailing Address - Street 1:362 MERIDIAN PARKE LN STE B
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46142-9425
Mailing Address - Country:US
Mailing Address - Phone:317-859-2905
Mailing Address - Fax:
Practice Address - Street 1:362 MERIDIAN PARKE LN STE B
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46142-9425
Practice Address - Country:US
Practice Address - Phone:317-859-2905
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-09
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07000797261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200035220Medicaid
IN480033210OtherRAILROAD MEDICARE
IN4743630001Medicare NSC
IN186990Medicare PIN
IN200035220Medicaid