Provider Demographics
NPI:1629048566
Name:QUEEN CITY FOOT AND ANKLE SPECIALISTS
Entity Type:Organization
Organization Name:QUEEN CITY FOOT AND ANKLE SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROXANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:BURGESS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:704-504-1004
Mailing Address - Street 1:11030 S TRYON ST
Mailing Address - Street 2:SUITE 308
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28273-6530
Mailing Address - Country:US
Mailing Address - Phone:704-504-1004
Mailing Address - Fax:704-504-0007
Practice Address - Street 1:11030 S TRYON ST
Practice Address - Street 2:SUITE 308
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28273-6530
Practice Address - Country:US
Practice Address - Phone:704-504-1004
Practice Address - Fax:704-504-0007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-24
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC461174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89081AVMedicaid
NC2347419Medicare PIN
NC89081AVMedicaid
NCU94994Medicare UPIN