Provider Demographics
NPI:1265014286
Name:MIDWEST FOOT AND ANKLE CLINIC LLC
Entity Type:Organization
Organization Name:MIDWEST FOOT AND ANKLE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NITIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SROA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:419-779-1180
Mailing Address - Street 1:13611 PUFF RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-8802
Mailing Address - Country:US
Mailing Address - Phone:419-799-1180
Mailing Address - Fax:
Practice Address - Street 1:208 COLUMBUS ST STE 200
Practice Address - Street 2:
Practice Address - City:HICKSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43526-1250
Practice Address - Country:US
Practice Address - Phone:416-799-1180
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-28
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty