Provider Demographics
NPI:1346255825
Name:MALTA FOOT SPECIALISTS
Entity Type:Organization
Organization Name:MALTA FOOT SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:MONGIOVI
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:518-899-3338
Mailing Address - Street 1:3 HEMPHILL PL STE 111
Mailing Address - Street 2:
Mailing Address - City:BALLSTON SPA
Mailing Address - State:NY
Mailing Address - Zip Code:12020-4420
Mailing Address - Country:US
Mailing Address - Phone:518-899-3338
Mailing Address - Fax:518-899-5025
Practice Address - Street 1:3 HEMPHILL PL STE 111
Practice Address - Street 2:
Practice Address - City:BALLSTON SPA
Practice Address - State:NY
Practice Address - Zip Code:12020-4420
Practice Address - Country:US
Practice Address - Phone:518-899-3338
Practice Address - Fax:518-899-5025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY6031640001Medicare NSC
NY54658AMedicare ID - Type UnspecifiedMEDICARE GROUP #