Provider Demographics
NPI:1265793111
Name:KSU FOOT & ANKLE CLINIC
Entity type:Organization
Organization Name:KSU FOOT & ANKLE CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:GREENE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-672-2982
Mailing Address - Street 1:6000 ROCKSIDE WOODS BLVD. N.
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:OH
Mailing Address - Zip Code:44131-2330
Mailing Address - Country:US
Mailing Address - Phone:216-916-5718
Mailing Address - Fax:216-916-7369
Practice Address - Street 1:6000 ROCKSIDE WOODS BLVD N
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:OH
Practice Address - Zip Code:44131-2330
Practice Address - Country:US
Practice Address - Phone:216-916-7369
Practice Address - Fax:216-916-7369
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-06
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
6703950002Medicare NSC
OHH117480Medicare PIN