Provider Demographics
NPI:1639769672
Name:ELLSWORTH FOOT AND ANKLE CLINIC
Entity type:Organization
Organization Name:ELLSWORTH FOOT AND ANKLE CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLSWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:801-253-6886
Mailing Address - Street 1:9980 S 300 W STE 300
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-3654
Mailing Address - Country:US
Mailing Address - Phone:801-253-6886
Mailing Address - Fax:
Practice Address - Street 1:505 FAIRBURN RD SW STE 100
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331-2012
Practice Address - Country:US
Practice Address - Phone:404-618-6077
Practice Address - Fax:801-253-6888
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ELLSWORTH FOOT AND ANKLE CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-01-23
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
No213ER0200XPodiatric Medicine & Surgery Service ProvidersPodiatristRadiologyGroup - Multi-Specialty
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports MedicineGroup - Multi-Specialty
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Multi-Specialty