Provider Demographics
NPI:1669074316
Name:BRIDGE CITY FOOT & ANKLE LLC
Entity type:Organization
Organization Name:BRIDGE CITY FOOT & ANKLE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PODIATRIC PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:STACH
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:503-805-4720
Mailing Address - Street 1:1720 SW HUNTINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-4752
Mailing Address - Country:US
Mailing Address - Phone:503-805-4720
Mailing Address - Fax:
Practice Address - Street 1:4770 SW WATSON AVE
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-0511
Practice Address - Country:US
Practice Address - Phone:503-427-8967
Practice Address - Fax:971-223-0096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-09
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty