Provider Demographics
NPI:1235462821
Name:RESTORATION FOOT & ANKLE PLLC
Entity Type:Organization
Organization Name:RESTORATION FOOT & ANKLE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:D
Authorized Official - Last Name:BEALSEY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:918-274-1557
Mailing Address - Street 1:DEPT 618
Mailing Address - Street 2:PO BOX 3500
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74018-3500
Mailing Address - Country:US
Mailing Address - Phone:918-274-1557
Mailing Address - Fax:918-274-8557
Practice Address - Street 1:800 W BOISE CIRCLE
Practice Address - Street 2:SUITE 270
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012
Practice Address - Country:US
Practice Address - Phone:918-274-1557
Practice Address - Fax:918-274-8557
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RESTORATION FOOT & ANKLE PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-09-14
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK6087660002Medicare NSC