Provider Demographics
NPI:1205025491
Name:FOOT & ANKLE WELLNESS CENTER
Entity Type:Organization
Organization Name:FOOT & ANKLE WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:937-509-0090
Mailing Address - Street 1:1871 W WILLIAM ST
Mailing Address - Street 2:
Mailing Address - City:DELAWARE
Mailing Address - State:OH
Mailing Address - Zip Code:43015-2255
Mailing Address - Country:US
Mailing Address - Phone:740-363-4373
Mailing Address - Fax:740-363-9560
Practice Address - Street 1:1871 W WILLIAM ST
Practice Address - Street 2:
Practice Address - City:DELAWARE
Practice Address - State:OH
Practice Address - Zip Code:43015-2255
Practice Address - Country:US
Practice Address - Phone:740-363-4373
Practice Address - Fax:740-363-9560
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-24
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36002064G213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9285121Medicare PIN
OH0485790001Medicare NSC