Provider Demographics
NPI:1083752364
Name:RALEIGH ST PODIATRY INC.
Entity Type:Organization
Organization Name:RALEIGH ST PODIATRY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:ACREE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:304-264-9525
Mailing Address - Street 1:411 S RALEIGH ST
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25401-2640
Mailing Address - Country:US
Mailing Address - Phone:304-264-9525
Mailing Address - Fax:304-264-9524
Practice Address - Street 1:411 S RALEIGH ST
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401-2640
Practice Address - Country:US
Practice Address - Phone:304-264-9525
Practice Address - Fax:304-264-9524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV00317213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001710711OtherBCBS
MD325MMedicare PIN
WV5064670002Medicare NSC
WV001710711OtherBCBS