Provider Demographics
NPI:1114047438
Name:ADVANCED FOOT AND ANKLE CLINICS PA
Entity Type:Organization
Organization Name:ADVANCED FOOT AND ANKLE CLINICS PA
Other - Org Name:ADVANCED FOOT AND ANKLE CLINICS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:SAMUEL
Authorized Official - Last Name:PIROTTA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:479-271-5353
Mailing Address - Street 1:903 SE 22ND ST
Mailing Address - Street 2:STE 1
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-4196
Mailing Address - Country:US
Mailing Address - Phone:479-271-5353
Mailing Address - Fax:479-254-0698
Practice Address - Street 1:903 SE 22ND ST
Practice Address - Street 2:STE 1
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-4196
Practice Address - Country:US
Practice Address - Phone:479-271-5353
Practice Address - Fax:479-254-0698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR133213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR129008748Medicaid
AR480033075OtherRR MCR
AR129007717OtherMEDICAID
U32668Medicare UPIN
5G120Medicare PIN
4297280002Medicare NSC