Provider Demographics
NPI:1710017256
Name:ANKLE AND FOOT CENTERS PC
Entity Type:Organization
Organization Name:ANKLE AND FOOT CENTERS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:GARY
Authorized Official - Last Name:TILLETT
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:503-246-2212
Mailing Address - Street 1:6274 SW CAPITOL HWY
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-2674
Mailing Address - Country:US
Mailing Address - Phone:503-246-2212
Mailing Address - Fax:503-246-4050
Practice Address - Street 1:6274 SW CAPITOL HWY
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-2674
Practice Address - Country:US
Practice Address - Phone:503-246-2212
Practice Address - Fax:503-246-4050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP00300213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DG6557OtherRR MCR
OR227113OtherOMAP
OR227113Medicaid
ORU71594Medicare UPIN
OR227113Medicaid
R112770Medicare PIN