Provider Demographics
NPI:1225107766
Name:ADVANCED FOOT & ANKLE
Entity Type:Organization
Organization Name:ADVANCED FOOT & ANKLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:G
Authorized Official - Last Name:OLSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:435-586-2225
Mailing Address - Street 1:1811 W ROYAL HUNTE DR
Mailing Address - Street 2:SUITE 2
Mailing Address - City:CEDAR CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84720-8273
Mailing Address - Country:US
Mailing Address - Phone:435-586-2225
Mailing Address - Fax:435-867-1909
Practice Address - Street 1:1811 W ROYAL HUNTE DR
Practice Address - Street 2:SUITE 2
Practice Address - City:CEDAR CITY
Practice Address - State:UT
Practice Address - Zip Code:84720-8273
Practice Address - Country:US
Practice Address - Phone:435-586-2225
Practice Address - Fax:435-867-1909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT106765-0501213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT52815688205001OtherBLUECROSS BLUESHIELD
UT107005417101OtherIHC
UT167286OtherDMBA
UT528156882001Medicaid
UT530941699001Medicaid
UT52815688205001OtherVALUECARE
UT52815688205001OtherBLUECROSS BLUESHIELD
UT=========OL1OtherEDUCATORS MUTUAL
UT=========OL1OtherEDUCATORS MUTUAL
UT528156882001Medicaid
UT=========006Medicaid
UT530941699001Medicaid
UT107005417101OtherIHC