Provider Demographics
NPI:1538514492
Name:MYPAFOOTDOCTOR
Entity Type:Organization
Organization Name:MYPAFOOTDOCTOR
Other - Org Name:SOUTH PENN FOOT, ANKLE AND WOUND CARE SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:MAXKA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:717-524-1034
Mailing Address - Street 1:1055 BALTIMORE ST STE 1
Mailing Address - Street 2:
Mailing Address - City:HANOVER
Mailing Address - State:PA
Mailing Address - Zip Code:17331-4400
Mailing Address - Country:US
Mailing Address - Phone:717-524-1034
Mailing Address - Fax:833-524-1034
Practice Address - Street 1:1055 BALTIMORE ST STE 1
Practice Address - Street 2:
Practice Address - City:HANOVER
Practice Address - State:PA
Practice Address - Zip Code:17331-4400
Practice Address - Country:US
Practice Address - Phone:717-524-1034
Practice Address - Fax:833-524-1034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-28
Last Update Date:2023-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC006213213E00000X
261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatricGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103298961Medicaid