Provider Demographics
NPI:1982662201
Name:PALM PODIATRY, LLC
Entity Type:Organization
Organization Name:PALM PODIATRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISRTATOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:RUTHANN
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:PRT, PMAC
Authorized Official - Phone:239-433-0064
Mailing Address - Street 1:15620 MCGREGOR BLVD
Mailing Address - Street 2:SUITE E
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-2528
Mailing Address - Country:US
Mailing Address - Phone:239-433-0064
Mailing Address - Fax:239-433-0224
Practice Address - Street 1:15620 MCGREGOR BLVD
Practice Address - Street 2:SUITE E
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-2528
Practice Address - Country:US
Practice Address - Phone:239-433-0064
Practice Address - Fax:239-433-0224
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO1528213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty