Provider Demographics
NPI:1508967886
Name:MEDFORD FOOT & ANKLE CLINIC, PC
Entity Type:Organization
Organization Name:MEDFORD FOOT & ANKLE CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:DEKORTE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:541-770-1225
Mailing Address - Street 1:713 GOLF VIEW DRIVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-9643
Mailing Address - Country:US
Mailing Address - Phone:541-770-1225
Mailing Address - Fax:541-770-1245
Practice Address - Street 1:713 GOLF VIEW DRIVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-9643
Practice Address - Country:US
Practice Address - Phone:541-770-1225
Practice Address - Fax:541-770-1245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR240546Medicaid
OR023677000OtherREGENCE BC
OR240546Medicaid
OR1297890001Medicare NSC