Provider Demographics
NPI:1164716387
Name:ACTIVE FEET, FOOT & ANKLE HEALTH CENTER
Entity Type:Organization
Organization Name:ACTIVE FEET, FOOT & ANKLE HEALTH CENTER
Other - Org Name:MIDWEST PODIATRY CENTER ST. ANTHONY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MOHR
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:612-788-8778
Mailing Address - Street 1:6625 LYNDALE AVE S STE 300
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55423-2491
Mailing Address - Country:US
Mailing Address - Phone:612-788-8778
Mailing Address - Fax:
Practice Address - Street 1:4001 STINSON BLVD STE 120
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55421-3424
Practice Address - Country:US
Practice Address - Phone:612-788-8778
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-06
Last Update Date:2018-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
6571310002Medicare NSC