Provider Demographics
NPI:1205869377
Name:CIRCLEVILLE FOOT & ANKLE LLC
Entity type:Organization
Organization Name:CIRCLEVILLE FOOT & ANKLE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN - MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:BROCK
Authorized Official - Middle Name:A
Authorized Official - Last Name:LIDEN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:740-474-3850
Mailing Address - Street 1:210 SHARON RD
Mailing Address - Street 2:P.O.BOX 865
Mailing Address - City:CIRCLEVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43113-1498
Mailing Address - Country:US
Mailing Address - Phone:740-474-3850
Mailing Address - Fax:740-477-3440
Practice Address - Street 1:210 SHARON RD
Practice Address - Street 2:SUITE A
Practice Address - City:CIRCLEVILLE
Practice Address - State:OH
Practice Address - Zip Code:43113-1498
Practice Address - Country:US
Practice Address - Phone:740-474-3850
Practice Address - Fax:740-477-3440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2619170Medicaid
OH5620650001OtherNEW DMERC C GROUP
OHDE4073OtherNEW RR MEDICARE C GROUP
OH5620650001OtherNEW DMERC C GROUP