Provider Demographics
NPI:1790822401
Name:HILLSBORO FOOT & ANKLE CLINIC, PC
Entity Type:Organization
Organization Name:HILLSBORO FOOT & ANKLE CLINIC, PC
Other - Org Name:HILLSBORO FOOT CLINIC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DPM
Authorized Official - Prefix:
Authorized Official - First Name:ELLIOT
Authorized Official - Middle Name:N
Authorized Official - Last Name:MICHAEL
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:503-648-2200
Mailing Address - Street 1:862 SE OAK ST STE 1A
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97123-4240
Mailing Address - Country:US
Mailing Address - Phone:503-648-2200
Mailing Address - Fax:503-693-1004
Practice Address - Street 1:862 SE OAK ST STE 1A
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-4240
Practice Address - Country:US
Practice Address - Phone:503-648-2200
Practice Address - Fax:503-693-1004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2008-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP00179213ES0103X
ORDP00315213ES0103X
ORDP00244213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
R0000WCMBVMedicare PIN
OR6124780001Medicare NSC
ORR139831Medicare PIN
OR0950720001Medicare NSC