Provider Demographics
NPI:1750323101
Name:FOOT & ANKLE CLINIC OF SOUTH BOSTON PC
Entity Type:Organization
Organization Name:FOOT & ANKLE CLINIC OF SOUTH BOSTON PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPERATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:MARVIN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:434-572-1444
Mailing Address - Street 1:405 A OAK LANE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:VA
Mailing Address - Zip Code:24592-1633
Mailing Address - Country:US
Mailing Address - Phone:434-572-1444
Mailing Address - Fax:434-575-8159
Practice Address - Street 1:405 A OAK LANE
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:VA
Practice Address - Zip Code:24592
Practice Address - Country:US
Practice Address - Phone:434-572-1444
Practice Address - Fax:434-575-8159
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103000792213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
480021195OtherRAILROAD
VAVAA102502OtherMEDICARE PTAN
T95735Medicare UPIN