Provider Demographics
NPI:1336468446
Name:MADISON LEE PODIATRY, INC
Entity Type:Organization
Organization Name:MADISON LEE PODIATRY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:PORTNOW
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:216-631-6080
Mailing Address - Street 1:6502 DETROIT AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44102-3014
Mailing Address - Country:US
Mailing Address - Phone:216-631-6080
Mailing Address - Fax:216-651-5002
Practice Address - Street 1:6502 DETROIT AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44102-3014
Practice Address - Country:US
Practice Address - Phone:216-631-6080
Practice Address - Fax:216-651-5002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-28
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2576213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2245814Medicaid
OH9282764Medicare PIN
OH6318540002Medicare NSC