Provider Demographics
NPI:1679504427
Name:HEALTHDRIVE PODIATRY GROUP, PC
Entity Type:Organization
Organization Name:HEALTHDRIVE PODIATRY GROUP, PC
Other - Org Name:HEALTHDRIVE PODIATRY GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TREASURER/PRACTICE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SHADI
Authorized Official - Middle Name:ADIB
Authorized Official - Last Name:ABBOUD
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:857-255-0486
Mailing Address - Street 1:100 CROSSING BLVD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:FRAMINGHAM
Mailing Address - State:MA
Mailing Address - Zip Code:01702-5555
Mailing Address - Country:US
Mailing Address - Phone:617-964-6681
Mailing Address - Fax:339-686-2561
Practice Address - Street 1:200 S EXECUTIVE DR
Practice Address - Street 2:SUITE 101
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-4216
Practice Address - Country:US
Practice Address - Phone:414-535-8134
Practice Address - Fax:414-535-8135
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2020-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WICD2116OtherMEDICARE RAILROAD
WI43264300Medicaid
WI43264300Medicaid
WICD2116OtherMEDICARE RAILROAD