Provider Demographics
NPI:1104861475
Name:HEALTHDRIVE PODIATRY GROUP, PA
Entity Type:Organization
Organization Name:HEALTHDRIVE PODIATRY GROUP, PA
Other - Org Name:HEALTHDRIVE PODIATRY GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/PRACTICE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:TRBOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-697-0727
Mailing Address - Street 1:100 CROSSING BLVD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:FRAMINGHAM
Mailing Address - State:MA
Mailing Address - Zip Code:01702-5555
Mailing Address - Country:US
Mailing Address - Phone:617-964-6681
Mailing Address - Fax:617-630-0141
Practice Address - Street 1:4201 FM 1960 RD W
Practice Address - Street 2:SUITE # 230
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77068-3414
Practice Address - Country:US
Practice Address - Phone:281-537-1599
Practice Address - Fax:281-537-1310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX171674801Medicaid
TX171674801Medicaid