Provider Demographics
NPI:1568541449
Name:ROBERT S WANE DPM PA
Entity Type:Organization
Organization Name:ROBERT S WANE DPM PA
Other - Org Name:CRYSTAL RIVER FOOT CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRES OF PA
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:S
Authorized Official - Last Name:WANE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:352-795-2142
Mailing Address - Street 1:9030 WEST FORT ISLAND TRAIL
Mailing Address - Street 2:SUITE 7
Mailing Address - City:CRYSTAL RIVER
Mailing Address - State:FL
Mailing Address - Zip Code:34429
Mailing Address - Country:US
Mailing Address - Phone:352-795-2142
Mailing Address - Fax:352-795-3044
Practice Address - Street 1:9030 WEST FORT ISLAND TRAIL
Practice Address - Street 2:SUITE 7
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34429
Practice Address - Country:US
Practice Address - Phone:352-795-2142
Practice Address - Fax:352-795-3044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2008-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO1141213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3852980001Medicare NSC
FLT55494Medicare UPIN
FL87665AMedicare PIN
FL87665Medicare ID - Type Unspecified