Provider Demographics
NPI:1689848038
Name:ETO PODIATRY CLINIC
Entity Type:Organization
Organization Name:ETO PODIATRY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL BILLER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:NEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-455-1400
Mailing Address - Street 1:112 W LOGAN ST
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-4731
Mailing Address - Country:US
Mailing Address - Phone:208-459-0891
Mailing Address - Fax:
Practice Address - Street 1:112 W LOGAN ST
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4731
Practice Address - Country:US
Practice Address - Phone:208-459-0891
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-16
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDT44252Medicare UPIN
ID1376010Medicare PIN