Provider Demographics
NPI:1740403955
Name:STURBRIDGE FOOT CARE, PC
Entity Type:Organization
Organization Name:STURBRIDGE FOOT CARE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:JEDRZYNSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-347-4900
Mailing Address - Street 1:118 MAIN ST
Mailing Address - Street 2:SUITE 4
Mailing Address - City:STURBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:01566-1533
Mailing Address - Country:US
Mailing Address - Phone:508-347-4900
Mailing Address - Fax:508-347-9339
Practice Address - Street 1:118 MAIN ST
Practice Address - Street 2:SUITE 4
Practice Address - City:STURBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01566-1533
Practice Address - Country:US
Practice Address - Phone:508-347-4900
Practice Address - Fax:508-347-9339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2129213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9706194Medicaid
983819OtherNETWORK HEALTH
W20203301OtherCIGNA
687-470OtherTUFTS
2574157OtherAETNA US HEALTHCARE
55384OtherFALLON
27-02436OtherUNITED HEALTH PLANS
333414OtherHARVARD PILGRIM
Y77291OtherBLUE CROSS BLUE SHIELD
=========OtherMULTIPLAN
=========OtherONE HEALTH
=========OtherGALAXY
Y77291OtherBLUE CROSS BLUE SHIELD
=========OtherUNICARE
55384OtherFALLON
687-470OtherTUFTS