Provider Demographics
NPI:1174657977
Name:THE FOOT AND ANKLE CLINIC LLC
Entity Type:Organization
Organization Name:THE FOOT AND ANKLE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTINA
Authorized Official - Middle Name:M
Authorized Official - Last Name:KOVACH
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:216-227-2194
Mailing Address - Street 1:PO BOX 80690
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44708-0690
Mailing Address - Country:US
Mailing Address - Phone:330-833-5692
Mailing Address - Fax:330-833-6085
Practice Address - Street 1:1730 W 25TH ST
Practice Address - Street 2:2E
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44113-3108
Practice Address - Country:US
Practice Address - Phone:216-227-2194
Practice Address - Fax:216-227-2196
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36002928213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2035158Medicaid
OH2035158Medicaid
OH5859140002Medicare NSC
OH9364591Medicare PIN