Provider Demographics
NPI:1326322884
Name:NORTHWOODS FOOT & ANKLE LLC
Entity Type:Organization
Organization Name:NORTHWOODS FOOT & ANKLE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:S
Authorized Official - Last Name:DIRKSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:715-358-3668
Mailing Address - Street 1:389 TROUT RIVER RD
Mailing Address - Street 2:
Mailing Address - City:MANITOWISH WATERS
Mailing Address - State:WI
Mailing Address - Zip Code:54545-9061
Mailing Address - Country:US
Mailing Address - Phone:715-358-3668
Mailing Address - Fax:715-318-0800
Practice Address - Street 1:1400 US HIGHWAY 51 N
Practice Address - Street 2:UNIT G
Practice Address - City:ARBOR VITAE
Practice Address - State:WI
Practice Address - Zip Code:54568-9504
Practice Address - Country:US
Practice Address - Phone:715-358-3668
Practice Address - Fax:715-318-0800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-03
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI98025213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIWI2558Medicare UPIN