Provider Demographics
NPI:1477739241
Name:ACTIVE PODIATRY P.C.
Entity Type:Organization
Organization Name:ACTIVE PODIATRY P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:YONG
Authorized Official - Middle Name:S
Authorized Official - Last Name:CHAE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:317-328-6622
Mailing Address - Street 1:1910 LAFAYETTE RD
Mailing Address - Street 2:
Mailing Address - City:CRAWFORDSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47933-1037
Mailing Address - Country:US
Mailing Address - Phone:765-362-7200
Mailing Address - Fax:765-362-4870
Practice Address - Street 1:1910 LAFAYETTE RD
Practice Address - Street 2:
Practice Address - City:CRAWFORDSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47933-1037
Practice Address - Country:US
Practice Address - Phone:765-362-7200
Practice Address - Fax:765-362-4870
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-11
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07000857A213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200178610BMedicaid
IN5679670002Medicare NSC
IN236070Medicare PIN
INU70572Medicare UPIN