Provider Demographics
NPI:1821132424
Name:FAYETTEVILLE FOOT AND ANKLE CENTER
Entity Type:Organization
Organization Name:FAYETTEVILLE FOOT AND ANKLE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:DEMETRI
Authorized Official - Suffix:JR
Authorized Official - Credentials:DPM
Authorized Official - Phone:910-483-3338
Mailing Address - Street 1:503 OWEN DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3433
Mailing Address - Country:US
Mailing Address - Phone:910-483-3338
Mailing Address - Fax:910-483-3386
Practice Address - Street 1:503 OWEN DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3433
Practice Address - Country:US
Practice Address - Phone:910-483-3338
Practice Address - Fax:910-483-3386
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC240213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890805FMedicaid
NC0153TOtherBLUE CROSS BLUE SHIELD
NC0153TOtherBLUE CROSS BLUE SHIELD
NC4756810001Medicare NSC
NC2432962AMedicare PIN