Provider Demographics
NPI:1619189560
Name:FAIRLAWN FOOT & ANKLE CLINIC INC
Entity Type:Organization
Organization Name:FAIRLAWN FOOT & ANKLE CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROPRIETOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:S
Authorized Official - Last Name:KELLOGG
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:330-836-6670
Mailing Address - Street 1:2640 W MARKET ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:FAIRLAWN
Mailing Address - State:OH
Mailing Address - Zip Code:44333-4202
Mailing Address - Country:US
Mailing Address - Phone:330-864-8501
Mailing Address - Fax:
Practice Address - Street 1:2640 W MARKET ST
Practice Address - Street 2:SUITE 301
Practice Address - City:FAIRLAWN
Practice Address - State:OH
Practice Address - Zip Code:44333-4202
Practice Address - Country:US
Practice Address - Phone:330-864-8501
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2014-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36-00-3216-K213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2884937Medicaid
OH9327051Medicare ID - Type Unspecified
OHU89018Medicare UPIN
OH4796730001Medicare NSC