Provider Demographics
NPI:1346781614
Name:WOODBURY FOOT CARE CENTRE LLC
Entity Type:Organization
Organization Name:WOODBURY FOOT CARE CENTRE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:AMY
Authorized Official - Middle Name:BETH
Authorized Official - Last Name:HERSKOWITZ
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:856-384-1333
Mailing Address - Street 1:722 MANTUA PIKE
Mailing Address - Street 2:SUITE10
Mailing Address - City:WOODBURY HEIGHTS
Mailing Address - State:NJ
Mailing Address - Zip Code:08097-1141
Mailing Address - Country:US
Mailing Address - Phone:856-384-1333
Mailing Address - Fax:856-384-1297
Practice Address - Street 1:722 MANTUA PIKE
Practice Address - Street 2:SUITE10
Practice Address - City:WOODBURY HEIGHTS
Practice Address - State:NJ
Practice Address - Zip Code:08097-1141
Practice Address - Country:US
Practice Address - Phone:856-384-1333
Practice Address - Fax:856-384-1297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-20
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00208400213E00000X
NJ25MD00328100213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4996003Medicaid
NJ4996003Medicaid