Provider Demographics
NPI:1568783553
Name:ADVANCED FOOT AND ANKLE ASSOCIATES PLLC
Entity Type:Organization
Organization Name:ADVANCED FOOT AND ANKLE ASSOCIATES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:OLIN
Authorized Official - Last Name:PENDLETON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:817-238-8400
Mailing Address - Street 1:6312 AZLE AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76135-2442
Mailing Address - Country:US
Mailing Address - Phone:817-238-8400
Mailing Address - Fax:817-238-8401
Practice Address - Street 1:6312 AZLE AVE
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:TX
Practice Address - Zip Code:76135-2442
Practice Address - Country:US
Practice Address - Phone:817-238-8400
Practice Address - Fax:817-238-8401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-14
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1916213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0029WAOtherBCBS TX
TX218408702Medicaid
TX218408703Medicaid
TXTXB105114Medicare PIN