Provider Demographics
NPI:1639235351
Name:NORTHEASTERN OHIO FOOT & ANKLE SURGICAL ASSOCIATES, INC.
Entity Type:Organization
Organization Name:NORTHEASTERN OHIO FOOT & ANKLE SURGICAL ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:A
Authorized Official - Last Name:BUCCILLI
Authorized Official - Suffix:JR
Authorized Official - Credentials:DPM
Authorized Official - Phone:330-687-7464
Mailing Address - Street 1:4403 CLOVER DR
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44266-8636
Mailing Address - Country:US
Mailing Address - Phone:330-687-7464
Mailing Address - Fax:
Practice Address - Street 1:4403 CLOVER DR
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:OH
Practice Address - Zip Code:44266-8636
Practice Address - Country:US
Practice Address - Phone:330-687-7464
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36.003352213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2538178Medicaid
OHBB9267914OtherDEA
OH5386000001Medicare NSC
OHV04013Medicare UPIN
OH2538178Medicaid