Provider Demographics
NPI:1275545311
Name:NORTHWEST FOOTCARE, LLC
Entity Type:Organization
Organization Name:NORTHWEST FOOTCARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:WILHELM
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:541-385-7129
Mailing Address - Street 1:1693 SW CHANDLER AVE
Mailing Address - Street 2:STE 280
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702
Mailing Address - Country:US
Mailing Address - Phone:541-385-7129
Mailing Address - Fax:541-385-7138
Practice Address - Street 1:1693 SW CHANDLER AVE
Practice Address - Street 2:STE 280
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702
Practice Address - Country:US
Practice Address - Phone:541-385-7129
Practice Address - Fax:541-385-7138
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-13
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR865318000OtherBLUE CROSS
OR213406Medicaid
ORDD4584OtherRAILROAD MEDICARE
OR=========OtherTAX ID NUMBER
OR213406Medicaid