Provider Demographics
NPI:1700145372
Name:PRESTIGE FOOT & ANKLE CENTER LLC
Entity Type:Organization
Organization Name:PRESTIGE FOOT & ANKLE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:MACHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-723-2111
Mailing Address - Street 1:784 MEDINA RD
Mailing Address - Street 2:STE # 107
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-9634
Mailing Address - Country:US
Mailing Address - Phone:234-248-4237
Mailing Address - Fax:330-723-2188
Practice Address - Street 1:784 MEDINA RD
Practice Address - Street 2:STE # 107
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-9634
Practice Address - Country:US
Practice Address - Phone:234-248-4237
Practice Address - Fax:330-723-2188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-16
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36003592213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty