Provider Demographics
NPI:1629256862
Name:RICK PIDALA
Entity Type:Organization
Organization Name:RICK PIDALA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICK
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:PIDALA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:440-439-8282
Mailing Address - Street 1:890 BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:OH
Mailing Address - Zip Code:44146-3612
Mailing Address - Country:US
Mailing Address - Phone:440-439-8282
Mailing Address - Fax:440-439-7863
Practice Address - Street 1:890 BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:OH
Practice Address - Zip Code:44146-3612
Practice Address - Country:US
Practice Address - Phone:440-439-8282
Practice Address - Fax:440-439-7863
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-08
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36.001964213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0444586Medicaid
PI0486491Medicare PIN
OH0444586Medicaid
OH0487410001Medicare NSC