Provider Demographics
NPI:1760618714
Name:GLENVILLE FOOT AND ANKLE CENTER, INC.
Entity Type:Organization
Organization Name:GLENVILLE FOOT AND ANKLE CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SAI
Authorized Official - Middle Name:MAN
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:216-268-0800
Mailing Address - Street 1:10701 ST. CLAIR AVE.
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44108
Mailing Address - Country:US
Mailing Address - Phone:931-206-4362
Mailing Address - Fax:606-257-5039
Practice Address - Street 1:10701 ST. CLAIR AVE.
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44108
Practice Address - Country:US
Practice Address - Phone:216-268-0800
Practice Address - Fax:216-268-0801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-04
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH213E00000X
OH36003361332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2973260Medicaid
OH6257520001Medicare NSC
OH9383621Medicare PIN