Provider Demographics
NPI:1942418348
Name:FOOT SPECIALISTS OF NORTHRIDGE - PODIATRY GROUP
Entity Type:Organization
Organization Name:FOOT SPECIALISTS OF NORTHRIDGE - PODIATRY GROUP
Other - Org Name:FOOT SPECIALISTS OF NORTHRIDGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:A
Authorized Official - Last Name:KELMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:818-363-9900
Mailing Address - Street 1:10515 BALBOA BLVD
Mailing Address - Street 2:STE 140
Mailing Address - City:GRANADA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91344-6343
Mailing Address - Country:US
Mailing Address - Phone:818-363-9900
Mailing Address - Fax:818-363-9915
Practice Address - Street 1:10515 BALBOA BLVD
Practice Address - Street 2:STE 140
Practice Address - City:GRANADA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91344-6343
Practice Address - Country:US
Practice Address - Phone:818-363-9900
Practice Address - Fax:818-363-9915
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2015-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2279213ES0103X
332B00000X
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
CAGR0000440Medicaid
CAGR0000440Medicaid
CAWE5943Medicare PIN