Provider Demographics
NPI:1689690711
Name:COMMONWEALTH FOOT AND ANKLE CENTER
Entity Type:Organization
Organization Name:COMMONWEALTH FOOT AND ANKLE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:M
Authorized Official - Last Name:SCHAFFER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:502-459-3338
Mailing Address - Street 1:1915 BISHOP LN
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40218-1901
Mailing Address - Country:US
Mailing Address - Phone:502-459-3338
Mailing Address - Fax:502-459-7509
Practice Address - Street 1:1915 BISHOP LN
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40218-1901
Practice Address - Country:US
Practice Address - Phone:502-459-3338
Practice Address - Fax:502-459-7509
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY00157213E00000X, 213ER0200X, 213ES0103X
KY649749332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No213ER0200XPodiatric Medicine & Surgery Service ProvidersPodiatristRadiologyGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY80903883Medicaid
KY2433742000OtherPASSPORT ADVANTAGE
IN201378810Medicaid
KY90004110Medicaid
KY90004110Medicaid
KY4039090001Medicare NSC
8628Medicare PIN
KYCN6832Medicare PIN