Provider Demographics
NPI:1760556104
Name:ADVANCED ANKLE AND FOOT CENTER, LLC
Entity Type:Organization
Organization Name:ADVANCED ANKLE AND FOOT CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PODIATRIST
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:B
Authorized Official - Last Name:VANCOURT
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:614-792-3668
Mailing Address - Street 1:PO BOX 1554
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-6554
Mailing Address - Country:US
Mailing Address - Phone:614-792-3668
Mailing Address - Fax:614-792-7615
Practice Address - Street 1:9759 FAIRWAY DR
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:OH
Practice Address - Zip Code:43065
Practice Address - Country:US
Practice Address - Phone:614-792-3668
Practice Address - Fax:614-792-7615
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-18
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE8613OtherRAILROAD MEDICARE
DE8613OtherRAILROAD MEDICARE
OH5601130001Medicare NSC