Provider Demographics
NPI:1801187737
Name:ELLSWORTH FOOT AND ANKLE CLINIC
Entity Type:Organization
Organization Name:ELLSWORTH FOOT AND ANKLE CLINIC
Other - Org Name:SUMMIT FOOT AND ANKLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLSWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:801-253-6886
Mailing Address - Street 1:9980 S 300 W STE 310
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-3654
Mailing Address - Country:US
Mailing Address - Phone:801-253-6886
Mailing Address - Fax:385-900-5928
Practice Address - Street 1:365 W 50 N STE W1
Practice Address - Street 2:
Practice Address - City:VERNAL
Practice Address - State:UT
Practice Address - Zip Code:84078-2010
Practice Address - Country:US
Practice Address - Phone:435-789-2062
Practice Address - Fax:801-253-6888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-26
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
213E00000X, 332B00000X
UT7414873-0501261QP1100X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT6583900001OtherPTAN
UT6583900001OtherPTAN