Provider Demographics
NPI:1659638104
Name:ADVANCED ARTHROSCOPIC FOOT & ANKLE ASSOCIATES, INC.
Entity Type:Organization
Organization Name:ADVANCED ARTHROSCOPIC FOOT & ANKLE ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ONWER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:EDWIN
Authorized Official - Last Name:PROMMERSBERGER
Authorized Official - Suffix:JR
Authorized Official - Credentials:DPM
Authorized Official - Phone:330-726-3348
Mailing Address - Street 1:940 WINDHAM CT
Mailing Address - Street 2:SUITE 3
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-5060
Mailing Address - Country:US
Mailing Address - Phone:330-726-3348
Mailing Address - Fax:
Practice Address - Street 1:940 WINDHAM CT
Practice Address - Street 2:SUITE 3
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-5060
Practice Address - Country:US
Practice Address - Phone:330-726-3348
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-20
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 213ES0103X
OH36-00-2619213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000177949OtherANTHEM
WV0099572000Medicaid
OH0774194Medicaid
WV000601363OtherBLUE SHIELD MOUNTAIN STATE
OHP00199462Medicare PIN
WV0655751Medicare PIN
OHT90004Medicare UPIN
OH0774194Medicaid