Provider Demographics
NPI:1902011125
Name:NORTH EAST FOOT CLINIC
Entity Type:Organization
Organization Name:NORTH EAST FOOT CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MORGAN
Authorized Official - Middle Name:TIMOTHY
Authorized Official - Last Name:HOLMES
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:814-725-2715
Mailing Address - Street 1:90 E MAIN ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:NORTH EAST
Mailing Address - State:PA
Mailing Address - Zip Code:16428-1319
Mailing Address - Country:US
Mailing Address - Phone:814-725-2715
Mailing Address - Fax:814-725-5186
Practice Address - Street 1:90 E MAIN ST
Practice Address - Street 2:SUITE 3
Practice Address - City:NORTH EAST
Practice Address - State:PA
Practice Address - Zip Code:16428-1319
Practice Address - Country:US
Practice Address - Phone:814-725-2715
Practice Address - Fax:814-725-5186
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC003377L213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012954200006Medicaid
PA0012954200006Medicaid
PAH062967Medicare ID - Type Unspecified