Provider Demographics
NPI:1336107515
Name:CENTRE FOOTCARE
Entity Type:Organization
Organization Name:CENTRE FOOTCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:E
Authorized Official - Last Name:MOLLO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:814-237-3338
Mailing Address - Street 1:602 E FOSTER AVE
Mailing Address - Street 2:
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16801-5724
Mailing Address - Country:US
Mailing Address - Phone:814-237-3338
Mailing Address - Fax:814-237-1680
Practice Address - Street 1:503 N FRONT ST
Practice Address - Street 2:
Practice Address - City:PHILIPSBURG
Practice Address - State:PA
Practice Address - Zip Code:16866-2125
Practice Address - Country:US
Practice Address - Phone:814-342-4844
Practice Address - Fax:814-342-4866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015594020009Medicaid
PA055035OtherHIGHMARK/BLUE SHIELD
PA275708OtherHEALTHAMERICA/ADVANTRA
PA02474800OtherKEYSTONE SENIOR BLUE
PA02474800OtherKEYSTONE SENIOR BLUE
PA0379060001Medicare NSC