Provider Demographics
NPI:1750627048
Name:CAMBRIDGE FOOT AND ANKLE CLINIC LLC
Entity type:Organization
Organization Name:CAMBRIDGE FOOT AND ANKLE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:763-689-2183
Mailing Address - Street 1:1001 1ST AVE E STE 180
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MN
Mailing Address - Zip Code:55008-1855
Mailing Address - Country:US
Mailing Address - Phone:763-689-2183
Mailing Address - Fax:763-689-6532
Practice Address - Street 1:1001 1ST AVE E STE 180
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MN
Practice Address - Zip Code:55008-1855
Practice Address - Country:US
Practice Address - Phone:763-689-2183
Practice Address - Fax:763-689-6532
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-14
Last Update Date:2013-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN303213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty