Provider Demographics
NPI:1639275951
Name:NORTHERN OHIO FOOT & ANKLE
Entity type:Organization
Organization Name:NORTHERN OHIO FOOT & ANKLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:FORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-461-0777
Mailing Address - Street 1:29001 CEDAR RD
Mailing Address - Street 2:309
Mailing Address - City:LYNDHURST
Mailing Address - State:OH
Mailing Address - Zip Code:44124-4062
Mailing Address - Country:US
Mailing Address - Phone:440-461-0777
Mailing Address - Fax:440-646-2433
Practice Address - Street 1:29001 CEDAR RD STE 309
Practice Address - Street 2:
Practice Address - City:LYNDHURST
Practice Address - State:OH
Practice Address - Zip Code:44124-4041
Practice Address - Country:US
Practice Address - Phone:440-461-0777
Practice Address - Fax:440-646-2433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2010-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36001417213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2735731Medicaid
OH9269536Medicare PIN
OH2735731Medicaid