Provider Demographics
NPI:1023293412
Name:ADVANCED FOOT AND ANKLE CARE
Entity type:Organization
Organization Name:ADVANCED FOOT AND ANKLE CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:R
Authorized Official - Last Name:BOREN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:330-477-4400
Mailing Address - Street 1:4642 HILLS DALES RD NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44708-1510
Mailing Address - Country:US
Mailing Address - Phone:330-477-4400
Mailing Address - Fax:
Practice Address - Street 1:4642 HILLS DALES RD NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44708-1510
Practice Address - Country:US
Practice Address - Phone:330-477-4400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-03
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36. 001949213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2056466Medicaid
9297531Medicare PIN
OH2056466Medicaid
T80490Medicare UPIN