Provider Demographics
NPI:1619954906
Name:ACHILLES FOOT & ANKLE SURGERY PC
Entity Type:Organization
Organization Name:ACHILLES FOOT & ANKLE SURGERY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:GARY
Authorized Official - Last Name:BLANK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:740-633-4188
Mailing Address - Street 1:2108 LUMBER AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-5350
Mailing Address - Country:US
Mailing Address - Phone:304-243-8799
Mailing Address - Fax:
Practice Address - Street 1:2108 LUMBER AVE STE 2
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-5350
Practice Address - Country:US
Practice Address - Phone:304-243-8799
Practice Address - Fax:740-633-4716
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-28
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36002569B213ES0103X
WV00239213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
5125771OtherAETNA
PA01756671Medicaid
OH2006260Medicaid
WV0099535001Medicaid
OH=========01OtherBWC
OH2006260Medicaid
WV=========001OtherMT STATE BCBS
=========002OtherMT STATE BCBS
=========003OtherMT STATE BCBS
5125771OtherAETNA
OH=========01OtherBWC
OH0850410002Medicare NSC
OH=========00OtherBWC
WV0850410001Medicare NSC
WV=========001OtherMT STATE BCBS
OH=========02OtherBWC