Provider Demographics
NPI:1932493350
Name:ACTIVE FEET , FOOT & ANKLE HEALTH CENTER
Entity Type:Organization
Organization Name:ACTIVE FEET , FOOT & ANKLE HEALTH CENTER
Other - Org Name:MIDWEST PODIATRY CENTERS COTTAGE GROVE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MOHR
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:612-798-0170
Mailing Address - Street 1:7430 80TH ST S
Mailing Address - Street 2:SUITE 104
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55016-3035
Mailing Address - Country:US
Mailing Address - Phone:612-788-8778
Mailing Address - Fax:
Practice Address - Street 1:7501 80TH ST S
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55016-3020
Practice Address - Country:US
Practice Address - Phone:651-459-9171
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-02
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
213ES0103X
MN631332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN6571310001Medicare NSC