Provider Demographics
NPI:1487826905
Name:REGIONAL FOOT & ANKLE CENTER PC
Entity Type:Organization
Organization Name:REGIONAL FOOT & ANKLE CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELMO
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:BALDASSARI
Authorized Official - Suffix:JR
Authorized Official - Credentials:DPM
Authorized Official - Phone:570-963-1974
Mailing Address - Street 1:1439 MONROE AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:DUNMORE
Mailing Address - State:PA
Mailing Address - Zip Code:18509-2497
Mailing Address - Country:US
Mailing Address - Phone:570-963-1974
Mailing Address - Fax:570-963-0762
Practice Address - Street 1:1439 MONROE AVE STE 3
Practice Address - Street 2:
Practice Address - City:DUNMORE
Practice Address - State:PA
Practice Address - Zip Code:18509-2497
Practice Address - Country:US
Practice Address - Phone:570-963-1974
Practice Address - Fax:570-963-0762
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-25
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC003666L213ES0103X
PASC-003666L332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0016528000002Medicaid
PAU65985Medicare UPIN
PA0016528000002Medicaid
PA895188Medicare PIN