Provider Demographics
NPI:1508811548
Name:BERRY LEAF FOOT & ANKLE CENTER LTD
Entity Type:Organization
Organization Name:BERRY LEAF FOOT & ANKLE CENTER LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:GRAYTOCK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:614-457-4774
Mailing Address - Street 1:1660 NW PROFESSIONAL PLZ
Mailing Address - Street 2:SUITE K
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43220-3854
Mailing Address - Country:US
Mailing Address - Phone:614-457-4774
Mailing Address - Fax:614-457-4795
Practice Address - Street 1:1660 NW PROFESSIONAL PLZ
Practice Address - Street 2:SUITE K
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43220-3854
Practice Address - Country:US
Practice Address - Phone:614-457-4774
Practice Address - Fax:614-457-4795
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2236182Medicaid
OHBE9313811Medicare ID - Type Unspecified