Provider Demographics
NPI:1164751418
Name:ACHILLES FOOT & ANKLE SURGERY PC
Entity Type:Organization
Organization Name:ACHILLES FOOT & ANKLE SURGERY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:G
Authorized Official - Last Name:BLANK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:740-695-4188
Mailing Address - Street 1:46898 NATIONAL RD W
Mailing Address - Street 2:
Mailing Address - City:ST. CLAIRSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43950
Mailing Address - Country:US
Mailing Address - Phone:740-695-4188
Mailing Address - Fax:
Practice Address - Street 1:46898 NATIONAL RD W
Practice Address - Street 2:
Practice Address - City:ST. CLAIRSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43950
Practice Address - Country:US
Practice Address - Phone:740-695-4188
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-16
Last Update Date:2009-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36-00-2569-B213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0850410002Medicare NSC