Provider Demographics
NPI:1255622544
Name:COMMONWEALTH FOOT AND ANKLE CARE LLC
Entity type:Organization
Organization Name:COMMONWEALTH FOOT AND ANKLE CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:BENGE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:270-598-4910
Mailing Address - Street 1:1945 SCOTTSVILLE RD
Mailing Address - Street 2:B-2 PMB 109
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-3376
Mailing Address - Country:US
Mailing Address - Phone:270-598-4910
Mailing Address - Fax:270-598-4930
Practice Address - Street 1:1030 BROOKHAVEN RD
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:KY
Practice Address - Zip Code:42134-2745
Practice Address - Country:US
Practice Address - Phone:270-598-4910
Practice Address - Fax:270-598-4930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-21
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY00337332B00000X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100204290Medicaid
KY7100161590Medicaid
KYDS0303Medicare PIN
KY6587130001Medicare NSC
KY7100161590Medicaid