Provider Demographics
NPI:1407040025
Name:PENNDOC FOOT & ANKLE CENTER, LLC
Entity Type:Organization
Organization Name:PENNDOC FOOT & ANKLE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE BILLER
Authorized Official - Prefix:
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:FOOT
Authorized Official - Last Name:EAKIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:181-436-2366
Mailing Address - Street 1:PO BOX 40
Mailing Address - Street 2:
Mailing Address - City:BRADFORD
Mailing Address - State:PA
Mailing Address - Zip Code:16701-0040
Mailing Address - Country:US
Mailing Address - Phone:814-362-3668
Mailing Address - Fax:814-362-0540
Practice Address - Street 1:133 MILL ST
Practice Address - Street 2:
Practice Address - City:BRADFORD
Practice Address - State:PA
Practice Address - Zip Code:16701-1408
Practice Address - Country:US
Practice Address - Phone:814-362-3668
Practice Address - Fax:814-362-0540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-28
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC003540L213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012260110001Medicaid
PA0012260110001Medicaid
PA602581Medicare Oscar/Certification
PA602581Medicare UPIN
PA602581Medicare PIN