Provider Demographics
NPI:1942549795
Name:ELLSWORTH FOOT AND ANKLE CLINIC
Entity Type:Organization
Organization Name:ELLSWORTH FOOT AND ANKLE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLSWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:801-550-0955
Mailing Address - Street 1:12523 S CREEK MEADOW RD STE 105
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84065-7299
Mailing Address - Country:US
Mailing Address - Phone:801-253-6886
Mailing Address - Fax:801-253-6888
Practice Address - Street 1:12523 S CREEK MEADOW RD STE 105
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84065
Practice Address - Country:US
Practice Address - Phone:801-253-6886
Practice Address - Fax:801-253-6888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-13
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8400193-0501213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
U000078263Medicare PIN