Provider Demographics
NPI:1225042591
Name:SOUTH COUNTY PODIATRY ASSOCIATES, INC.
Entity Type:Organization
Organization Name:SOUTH COUNTY PODIATRY ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:ZERVOS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:401-789-8912
Mailing Address - Street 1:70 KENYON AVE
Mailing Address - Street 2:SUITE 212
Mailing Address - City:WAKEFIELD
Mailing Address - State:RI
Mailing Address - Zip Code:02879-4239
Mailing Address - Country:US
Mailing Address - Phone:401-789-8912
Mailing Address - Fax:401-782-8702
Practice Address - Street 1:70 KENYON AVE
Practice Address - Street 2:SUITE 212
Practice Address - City:WAKEFIELD
Practice Address - State:RI
Practice Address - Zip Code:02879-4239
Practice Address - Country:US
Practice Address - Phone:401-789-8912
Practice Address - Fax:401-782-8702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-29
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9082009Medicaid
RI9082009Medicaid