Provider Demographics
NPI:1326180795
Name:PINES FOOT & ANKLE SURGICAL GROUP, INC.
Entity Type:Organization
Organization Name:PINES FOOT & ANKLE SURGICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:L
Authorized Official - Last Name:VALDES
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:954-704-2888
Mailing Address - Street 1:PO BOX 825892
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33082-5892
Mailing Address - Country:US
Mailing Address - Phone:954-704-2888
Mailing Address - Fax:954-704-0227
Practice Address - Street 1:17901 NW 5TH ST
Practice Address - Street 2:SUITE # 106
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33029-2810
Practice Address - Country:US
Practice Address - Phone:954-704-2888
Practice Address - Fax:954-704-0227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2010-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO-2687213E00000X, 213EP1101X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL390463600Medicaid
FL38201Medicare ID - Type Unspecified
FL390463600Medicaid