Provider Demographics
NPI:1356588917
Name:ADVANCED FEET AND ANKLE CARE
Entity type:Organization
Organization Name:ADVANCED FEET AND ANKLE CARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:M
Authorized Official - Last Name:GROSSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:732-679-4330
Mailing Address - Street 1:2477 HIGHWAY 516
Mailing Address - Street 2:
Mailing Address - City:OLD BRIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:08857-4603
Mailing Address - Country:US
Mailing Address - Phone:732-679-4330
Mailing Address - Fax:732-679-4777
Practice Address - Street 1:2477 HIGHWAY 516
Practice Address - Street 2:
Practice Address - City:OLD BRIDGE
Practice Address - State:NJ
Practice Address - Zip Code:08857-4603
Practice Address - Country:US
Practice Address - Phone:732-679-4330
Practice Address - Fax:732-679-4777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-19
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ213ES0103X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0186350Medicaid
NJDO7594Medicare PIN
NJ148440Medicare PIN
NJ0186350Medicaid