Provider Demographics
NPI:1285834929
Name:ADVANCED FOOT & ANKLE CENTER SC
Entity Type:Organization
Organization Name:ADVANCED FOOT & ANKLE CENTER SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:
Authorized Official - Last Name:CHISM
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:715-536-7444
Mailing Address - Street 1:410 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:MERRILL
Mailing Address - State:WI
Mailing Address - Zip Code:54452
Mailing Address - Country:US
Mailing Address - Phone:715-536-7444
Mailing Address - Fax:715-536-1547
Practice Address - Street 1:410 E 2ND ST
Practice Address - Street 2:
Practice Address - City:MERRILL
Practice Address - State:WI
Practice Address - Zip Code:54452-2319
Practice Address - Country:US
Practice Address - Phone:715-536-7444
Practice Address - Fax:715-536-1547
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-20
Last Update Date:2010-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI748213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000000485016OtherWI BLUE SHIELD
WI000086520OtherRAILROAD MEDICARE
1197940001OtherDMERC REGION B
WI43223800Medicaid
1197940001OtherDMERC REGION B
WI000000485016OtherWI BLUE SHIELD
WI000086520OtherRAILROAD MEDICARE