Provider Demographics
NPI:1770614141
Name:PODIATRIC MEDICAL SPECIALISTS LLC
Entity type:Organization
Organization Name:PODIATRIC MEDICAL SPECIALISTS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DPM OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:PERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-439-4600
Mailing Address - Street 1:1354 CLARK ST
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:OH
Mailing Address - Zip Code:43725-9614
Mailing Address - Country:US
Mailing Address - Phone:740-439-4600
Mailing Address - Fax:740-432-8712
Practice Address - Street 1:1354 CLARK ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:OH
Practice Address - Zip Code:43725-9614
Practice Address - Country:US
Practice Address - Phone:740-439-4600
Practice Address - Fax:740-432-8712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36002747213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2111397Medicaid
OH9306482Medicare PIN
OH1023530001Medicare NSC
OH9306481Medicare PIN