Provider Demographics
NPI:1548798234
Name:MADISON PODIATRY LLC
Entity Type:Organization
Organization Name:MADISON PODIATRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:POLLACK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:917-873-6483
Mailing Address - Street 1:971 WILSON AVE
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-1863
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:52 SKYLINE DR
Practice Address - Street 2:
Practice Address - City:RINGWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07456-2020
Practice Address - Country:US
Practice Address - Phone:973-962-7775
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-25
Last Update Date:2017-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00322600213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJG300078632OtherMEDICARE