Provider Demographics
NPI:1932297264
Name:EASTOVER FOOT & ANKLE PA
Entity Type:Organization
Organization Name:EASTOVER FOOT & ANKLE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:VICTOR
Authorized Official - Last Name:FUTERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:704-841-4000
Mailing Address - Street 1:PO BOX 1539
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28106-1539
Mailing Address - Country:US
Mailing Address - Phone:704-841-4000
Mailing Address - Fax:704-841-4338
Practice Address - Street 1:428 N. TRADE STREET
Practice Address - Street 2:SUITE 100
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-5017
Practice Address - Country:US
Practice Address - Phone:704-841-4000
Practice Address - Fax:704-841-4338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2015-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200001392347213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0172MOtherBLUE CROSS BLUE SHIELD NC
NC890172MMedicaid
NC0172MOtherBLUE CROSS BLUE SHIELD NC
NCCA5050Medicare PIN
NC890172MMedicaid