Provider Demographics
NPI:1477715845
Name:TRI-COUNTY FOOT AND ANKLE CENTER INC
Entity Type:Organization
Organization Name:TRI-COUNTY FOOT AND ANKLE CENTER INC
Other - Org Name:TIMOTHY D. KISTLER, DPM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:D
Authorized Official - Last Name:KISTLER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:419-435-3554
Mailing Address - Street 1:614 W LYTLE ST
Mailing Address - Street 2:
Mailing Address - City:FOSTORIA
Mailing Address - State:OH
Mailing Address - Zip Code:44830-3422
Mailing Address - Country:US
Mailing Address - Phone:419-435-3554
Mailing Address - Fax:
Practice Address - Street 1:614 W LYTLE ST
Practice Address - Street 2:
Practice Address - City:FOSTORIA
Practice Address - State:OH
Practice Address - Zip Code:44830-3422
Practice Address - Country:US
Practice Address - Phone:419-435-3554
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-27
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH36003099213ES0103X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2092239Medicaid
OH000000141026OtherANTHEM BLUE CROSS BLUE SHIELD
OH480026415OtherMEDICARE RR
OH272741141003OtherMEDICAL MUTUAL OF OHIO
OH2092239Medicaid
OHU63761Medicare UPIN
OH0863401Medicare PIN