Provider Demographics
NPI:1407031016
Name:PHOENIX FOOT SURGEON INC
Entity Type:Organization
Organization Name:PHOENIX FOOT SURGEON INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:
Authorized Official - Last Name:ROEDER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:480-507-7560
Mailing Address - Street 1:1501 N GILBERT RD STE 120
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-2393
Mailing Address - Country:US
Mailing Address - Phone:480-507-7560
Mailing Address - Fax:480-507-7509
Practice Address - Street 1:1501 N GILBERT RD STE 120
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2393
Practice Address - Country:US
Practice Address - Phone:480-507-7560
Practice Address - Fax:480-507-7509
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-02
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ497213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty