Provider Demographics
NPI:1295014462
Name:MAPLE SHADE FOOT AND ANKLE SPECIALISTS, LLC
Entity Type:Organization
Organization Name:MAPLE SHADE FOOT AND ANKLE SPECIALISTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:WINIEWICZ
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:856-779-8080
Mailing Address - Street 1:2 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MAPLE SHADE
Mailing Address - State:NJ
Mailing Address - Zip Code:08052-2620
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MAPLE SHADE
Practice Address - State:NJ
Practice Address - Zip Code:08052-2620
Practice Address - Country:US
Practice Address - Phone:856-779-8080
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-05
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6692160001Medicare NSC