Provider Demographics
NPI:1376619924
Name:ADVANCED MEDICAL FOOTCARE, LLC
Entity Type:Organization
Organization Name:ADVANCED MEDICAL FOOTCARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:A
Authorized Official - Last Name:CALLAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:203-330-8080
Mailing Address - Street 1:1817 BLACK ROCK TURNPIKE
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06825-3546
Mailing Address - Country:US
Mailing Address - Phone:203-330-8080
Mailing Address - Fax:203-334-6924
Practice Address - Street 1:1817 BLACK ROCK TURNPIKE
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06825-3546
Practice Address - Country:US
Practice Address - Phone:203-330-8080
Practice Address - Fax:203-334-6924
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT5454010001Medicare NSC
T22259Medicare UPIN
480000953Medicare ID - Type Unspecified