Provider Demographics
NPI:1407921380
Name:LOCK HAVEN PODIATRY, L.L.C.
Entity Type:Organization
Organization Name:LOCK HAVEN PODIATRY, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:ROSSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:814-355-1850
Mailing Address - Street 1:610 HIGH ST
Mailing Address - Street 2:SPECIALISTS CLINIC
Mailing Address - City:LOCK HAVEN
Mailing Address - State:PA
Mailing Address - Zip Code:17745-3018
Mailing Address - Country:US
Mailing Address - Phone:570-748-1270
Mailing Address - Fax:570-748-1271
Practice Address - Street 1:610 HIGH ST
Practice Address - Street 2:SPECIALISTS CLINIC
Practice Address - City:LOCK HAVEN
Practice Address - State:PA
Practice Address - Zip Code:17745-3018
Practice Address - Country:US
Practice Address - Phone:570-748-1270
Practice Address - Fax:570-748-1271
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC005592213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PALO1774288OtherHIGHMARK BCBS
PA1014668430001Medicaid
PALO096829Medicare ID - Type Unspecified