Provider Demographics
NPI:1407951866
Name:COUNTRY FOOT CARE PC
Entity Type:Organization
Organization Name:COUNTRY FOOT CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:BROOK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:516-294-8877
Mailing Address - Street 1:155 MINEOLA BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-3920
Mailing Address - Country:US
Mailing Address - Phone:516-741-3338
Mailing Address - Fax:
Practice Address - Street 1:479 WILLIS AVE
Practice Address - Street 2:
Practice Address - City:WILLISTON PARK
Practice Address - State:NY
Practice Address - Zip Code:11596-1725
Practice Address - Country:US
Practice Address - Phone:516-741-3338
Practice Address - Fax:516-741-4601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2008-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN003218213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
5359090001Medicare NSC
NYPGW681Medicare PIN