Provider Demographics
NPI:1508264680
Name:OHIO PODIATRIC PHYSICIANS AND SURGEONS GROUP, LLC
Entity Type:Organization
Organization Name:OHIO PODIATRIC PHYSICIANS AND SURGEONS GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:BEAU
Authorized Official - Middle Name:GREGORY
Authorized Official - Last Name:BORTEL
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:419-893-5757
Mailing Address - Street 1:5757 MONCLOVA RD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-1863
Mailing Address - Country:US
Mailing Address - Phone:419-893-5757
Mailing Address - Fax:419-893-5399
Practice Address - Street 1:5757 MONCLOVA RD
Practice Address - Street 2:SUITE 5
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-1863
Practice Address - Country:US
Practice Address - Phone:419-893-5757
Practice Address - Fax:419-893-5399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-05
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36003428213EP1101X, 213ES0103X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty