Provider Demographics
NPI:1770564288
Name:EAST PENN PODIATRY ASSOC
Entity type:Organization
Organization Name:EAST PENN PODIATRY ASSOC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:STEVENS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:610-683-5067
Mailing Address - Street 1:91 CONSTITUTION BLVD
Mailing Address - Street 2:
Mailing Address - City:KUTZTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19530-1736
Mailing Address - Country:US
Mailing Address - Phone:610-683-5067
Mailing Address - Fax:610-683-3823
Practice Address - Street 1:91 CONSTITUTION BLVD
Practice Address - Street 2:
Practice Address - City:KUTZTOWN
Practice Address - State:PA
Practice Address - Zip Code:19530-1736
Practice Address - Country:US
Practice Address - Phone:610-683-5067
Practice Address - Fax:610-683-3823
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC003061L213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
02551100OtherBLUE CROSS
EA741806Medicare ID - Type Unspecified
T30753Medicare UPIN