Provider Demographics
NPI:1255402442
Name:PODIATRY ASSOC OF THE OHIO COLLEGE OF PODIATRIC MEDICINE
Entity type:Organization
Organization Name:PODIATRY ASSOC OF THE OHIO COLLEGE OF PODIATRIC MEDICINE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:DEMORE
Authorized Official - Suffix:III
Authorized Official - Credentials:DPM
Authorized Official - Phone:216-591-1311
Mailing Address - Street 1:PO BOX 72350
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44192-0002
Mailing Address - Country:US
Mailing Address - Phone:216-591-1311
Mailing Address - Fax:
Practice Address - Street 1:3609 PARK EAST DR
Practice Address - Street 2:NORTH 406
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-4331
Practice Address - Country:US
Practice Address - Phone:216-591-1311
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-11
Last Update Date:2009-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0851823Medicaid
OH9247011Medicare PIN
OH0851823Medicaid