Provider Demographics
NPI:1912017021
Name:NORTH BAY FOOT & ANKLE CENTER INC
Entity Type:Organization
Organization Name:NORTH BAY FOOT & ANKLE CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:REDKO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-769-8481
Mailing Address - Street 1:1400 PROFESSIONAL DR
Mailing Address - Street 2:# 102
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954
Mailing Address - Country:US
Mailing Address - Phone:707-769-8481
Mailing Address - Fax:707-769-0751
Practice Address - Street 1:1400 PROFESSIONAL DR
Practice Address - Street 2:# 102
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954
Practice Address - Country:US
Practice Address - Phone:707-769-8481
Practice Address - Fax:707-769-0751
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2013-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE1458213E00000X
CAE4517213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ26258ZMedicaid
CA0470760001Medicare NSC
T10968Medicare UPIN
CAZZZ26258ZMedicaid