Provider Demographics
NPI:1598776833
Name:FLEETWOOD FOOTCARE CENTER, PC
Entity Type:Organization
Organization Name:FLEETWOOD FOOTCARE CENTER, PC
Other - Org Name:FLEETWOOD FOOT AND ANKLE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:L
Authorized Official - Last Name:GEIST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-944-6537
Mailing Address - Street 1:12 LENHART RD
Mailing Address - Street 2:PO BOX 425
Mailing Address - City:FLEETWOOD
Mailing Address - State:PA
Mailing Address - Zip Code:19522-0425
Mailing Address - Country:US
Mailing Address - Phone:610-944-6537
Mailing Address - Fax:610-944-8152
Practice Address - Street 1:12 LENHART RD
Practice Address - Street 2:
Practice Address - City:FLEETWOOD
Practice Address - State:PA
Practice Address - Zip Code:19522-8613
Practice Address - Country:US
Practice Address - Phone:610-944-6537
Practice Address - Fax:610-944-8152
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2019-06-06
Deactivation Date:2008-05-05
Deactivation Code:
Reactivation Date:2008-06-04
Provider Licenses
StateLicense IDTaxonomies
PA213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA02340700OtherCAPITAL BLUE CMS
PA1016356050001Medicaid
PA02340700OtherBC
PA1602963OtherBS
PA1016356050001Medicaid
PA5150850001Medicare NSC