Provider Demographics
NPI:1598001141
Name:PREMIUM FOOT CARE, LLC
Entity Type:Organization
Organization Name:PREMIUM FOOT CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MORRIS
Authorized Official - Middle Name:TYRONE
Authorized Official - Last Name:HAYWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:973-222-9503
Mailing Address - Street 1:PO BOX 202506
Mailing Address - Street 2:
Mailing Address - City:SHAKER HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44120-8125
Mailing Address - Country:US
Mailing Address - Phone:216-721-3338
Mailing Address - Fax:216-721-2375
Practice Address - Street 1:8819 QUINCY AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-3445
Practice Address - Country:US
Practice Address - Phone:216-721-3338
Practice Address - Fax:216-721-2375
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-28
Last Update Date:2012-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1316945884Medicare PIN