Provider Demographics
NPI:1215232137
Name:CHAGRIN VALLEY FOOT AND ANKLE SPECIALISTS INC
Entity Type:Organization
Organization Name:CHAGRIN VALLEY FOOT AND ANKLE SPECIALISTS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACQUELYN
Authorized Official - Middle Name:L
Authorized Official - Last Name:QUERCIOLI
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:440-285-4010
Mailing Address - Street 1:11850 MAYFIELD RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:CHARDON
Mailing Address - State:OH
Mailing Address - Zip Code:44024-8370
Mailing Address - Country:US
Mailing Address - Phone:440-285-4010
Mailing Address - Fax:877-561-7535
Practice Address - Street 1:11850 MAYFIELD RD
Practice Address - Street 2:SUITE 2
Practice Address - City:CHARDON
Practice Address - State:OH
Practice Address - Zip Code:44024-8370
Practice Address - Country:US
Practice Address - Phone:440-285-4010
Practice Address - Fax:877-561-7535
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-25
Last Update Date:2011-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3136172Medicaid
OH9394461Medicare PIN