Provider Demographics
NPI:1972996189
Name:BANGOR PODIATRY LLC
Entity Type:Organization
Organization Name:BANGOR PODIATRY LLC
Other - Org Name:BANGOR PODIATRY OF BRODHEADSVILLE
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHERALYN
Authorized Official - Middle Name:
Authorized Official - Last Name:PERKINS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:610-588-6621
Mailing Address - Street 1:325 BLUE VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:PA
Mailing Address - Zip Code:18013-1526
Mailing Address - Country:US
Mailing Address - Phone:610-588-6621
Mailing Address - Fax:610-588-6307
Practice Address - Street 1:1636 ROUTE 209
Practice Address - Street 2:BK PLAZA, UNIT 1
Practice Address - City:BRODHEADSVILLE
Practice Address - State:PA
Practice Address - Zip Code:18322-7799
Practice Address - Country:US
Practice Address - Phone:570-992-5779
Practice Address - Fax:570-992-5806
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BANGOR PODIATRY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-03-12
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC004468L213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty