Provider Demographics
NPI:1457839839
Name:SUPERIOR PODIATRY, LLC
Entity Type:Organization
Organization Name:SUPERIOR PODIATRY, LLC
Other - Org Name:ST JOHNS FOOT AND ANKLE SPECIALISTS, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:RANDALL
Authorized Official - Last Name:NORTHRUP
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:904-436-8001
Mailing Address - Street 1:1690 US HIGHWAY 1 S STE C
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084-6024
Mailing Address - Country:US
Mailing Address - Phone:904-436-8001
Mailing Address - Fax:904-377-6776
Practice Address - Street 1:1690 US HIGHWAY 1 S STE C
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-6024
Practice Address - Country:US
Practice Address - Phone:904-436-8001
Practice Address - Fax:904-377-6776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-30
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101522100Medicaid