Provider Demographics
NPI:1902044035
Name:FOOT AND ANKLE CENTER OF PHILADELPHIA
Entity Type:Organization
Organization Name:FOOT AND ANKLE CENTER OF PHILADELPHIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:F
Authorized Official - Last Name:BOC
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:215-568-3510
Mailing Address - Street 1:235 N BROAD STREET
Mailing Address - Street 2:SUITE 300
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107
Mailing Address - Country:US
Mailing Address - Phone:215-568-3510
Mailing Address - Fax:215-568-3529
Practice Address - Street 1:235 N BROAD STREET
Practice Address - Street 2:SUITE 300
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107
Practice Address - Country:US
Practice Address - Phone:215-568-3510
Practice Address - Fax:215-568-3529
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FOOT AND ANKLE CENTER OF PHILA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-01-28
Last Update Date:2009-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC002554L213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0097805810Medicaid