Provider Demographics
NPI:1336367416
Name:SANDY RIVER PODIATRY, PA
Entity Type:Organization
Organization Name:SANDY RIVER PODIATRY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:207-779-1002
Mailing Address - Street 1:114 PERHAM ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:ME
Mailing Address - Zip Code:04938-1520
Mailing Address - Country:US
Mailing Address - Phone:207-779-1002
Mailing Address - Fax:207-779-1091
Practice Address - Street 1:114 PERHAM ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:ME
Practice Address - Zip Code:04938-1520
Practice Address - Country:US
Practice Address - Phone:207-779-1002
Practice Address - Fax:207-779-1091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPOD1034213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME134880000Medicaid
MEME1822Medicare ID - Type Unspecified
ME134880000Medicaid