Provider Demographics
NPI:1639354673
Name:MECKLENBURG FOOT & ANKLE ASSOCIATES
Entity Type:Organization
Organization Name:MECKLENBURG FOOT & ANKLE ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:M
Authorized Official - Last Name:LIESMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:704-442-8433
Mailing Address - Street 1:3535 RANDOLPH RD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-1086
Mailing Address - Country:US
Mailing Address - Phone:704-442-8433
Mailing Address - Fax:704-442-8471
Practice Address - Street 1:3535 RANDOLPH RD
Practice Address - Street 2:SUITE 107
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1086
Practice Address - Country:US
Practice Address - Phone:704-442-8433
Practice Address - Fax:704-442-8471
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-09
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC356213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1202020001Medicare PIN
NCU54728Medicare UPIN