Provider Demographics
NPI:1679502843
Name:ASSOCIATED FOOT & ANKLE CLINIC LLC
Entity Type:Organization
Organization Name:ASSOCIATED FOOT & ANKLE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO OWNER PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:M
Authorized Official - Last Name:SAGE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:608-362-0758
Mailing Address - Street 1:2950 PRAIRIE AVENUE
Mailing Address - Street 2:3
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-1899
Mailing Address - Country:US
Mailing Address - Phone:608-362-0758
Mailing Address - Fax:608-362-7310
Practice Address - Street 1:2950 PRAIRIE AVENUE
Practice Address - Street 2:3
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-1899
Practice Address - Country:US
Practice Address - Phone:608-362-0758
Practice Address - Fax:608-362-7310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43264700Medicaid
WI43264700Medicaid