Provider Demographics
NPI:1376829739
Name:PERFORMANCE PODIATRY, INC.
Entity Type:Organization
Organization Name:PERFORMANCE PODIATRY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RODNEY
Authorized Official - Middle Name:W
Authorized Official - Last Name:ROOF
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:513-563-6228
Mailing Address - Street 1:10475 READING RD
Mailing Address - Street 2:SUITE 404
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45241-2563
Mailing Address - Country:US
Mailing Address - Phone:513-563-6228
Mailing Address - Fax:513-577-7261
Practice Address - Street 1:6350 GLENWAY AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45211-6378
Practice Address - Country:US
Practice Address - Phone:513-563-6228
Practice Address - Fax:513-577-7261
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-31
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36003134213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3075872Medicaid