Provider Demographics
NPI:1972875854
Name:ADVANCED FOOT & ANKLE CENTER LLC
Entity Type:Organization
Organization Name:ADVANCED FOOT & ANKLE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRUNDY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:219-405-3775
Mailing Address - Street 1:27 ASPEN RD
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-1027
Mailing Address - Country:US
Mailing Address - Phone:219-405-3775
Mailing Address - Fax:219-405-3775
Practice Address - Street 1:111 BOYD CIR
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-7016
Practice Address - Country:US
Practice Address - Phone:219-405-3775
Practice Address - Fax:219-405-3775
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-07
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07000941A213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty