Provider Demographics
NPI:1891977088
Name:TWIN RIVERS PODIATRY OF BOYERTOWN
Entity Type:Organization
Organization Name:TWIN RIVERS PODIATRY OF BOYERTOWN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECT OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:KIRK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:610-367-7000
Mailing Address - Street 1:5TH AND MONTGOMERY
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BOYERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19512-1300
Mailing Address - Country:US
Mailing Address - Phone:610-367-7000
Mailing Address - Fax:610-367-4559
Practice Address - Street 1:5TH AND MONTGOMERY
Practice Address - Street 2:SUITE 102
Practice Address - City:BOYERTOWN
Practice Address - State:PA
Practice Address - Zip Code:19512-1300
Practice Address - Country:US
Practice Address - Phone:610-367-7000
Practice Address - Fax:610-367-4559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-29
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC004605L213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA3126386000OtherINDEPENDENCE BLUE CROSS
PA3126386000OtherAMERIHEALTH
PA1997171OtherHIGHMARK BLUE SHIELD
PA50074066OtherCAPITAL BLUE CROSS
PA6075530001Medicare NSC
PAU95764Medicare UPIN