Provider Demographics
NPI:1619192655
Name:HUDSON FOOT CLINIC, INC.
Entity Type:Organization
Organization Name:HUDSON FOOT CLINIC, INC.
Other - Org Name:WESTERN RESERVE FOOT CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:HARLEY
Authorized Official - Last Name:NIXON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:330-689-3338
Mailing Address - Street 1:4495 DARROW RD
Mailing Address - Street 2:
Mailing Address - City:STOW
Mailing Address - State:OH
Mailing Address - Zip Code:44224-1854
Mailing Address - Country:US
Mailing Address - Phone:330-689-3338
Mailing Address - Fax:330-689-0282
Practice Address - Street 1:4495 DARROW RD
Practice Address - Street 2:
Practice Address - City:STOW
Practice Address - State:OH
Practice Address - Zip Code:44224-1854
Practice Address - Country:US
Practice Address - Phone:330-689-3338
Practice Address - Fax:330-689-0282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2009-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36-00-2719213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2915742Medicaid
OH480016282OtherMEDICARE RAILROAD
OHHU9268711Medicare PIN
OH2915742Medicaid