Provider Demographics
NPI:1023059102
Name:STARK COUNTY FOOT & ANKLE CLINIC
Entity type:Organization
Organization Name:STARK COUNTY FOOT & ANKLE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE CLAIMS PROCESSOR
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:DIEHL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-833-5692
Mailing Address - Street 1:323 MARION AVE NW
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MASSILLON
Mailing Address - State:OH
Mailing Address - Zip Code:44646
Mailing Address - Country:US
Mailing Address - Phone:330-837-7715
Mailing Address - Fax:330-837-7645
Practice Address - Street 1:323 MARION AVE NW
Practice Address - Street 2:SUITE 101
Practice Address - City:MASSILLON
Practice Address - State:OH
Practice Address - Zip Code:44646
Practice Address - Country:US
Practice Address - Phone:330-837-7715
Practice Address - Fax:330-837-7645
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH36002987213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2413650Medicaid
OH9335911Medicare ID - Type Unspecified