Provider Demographics
NPI:1770704819
Name:THE ORTHOPAEDIC CENTER FOR FOOT & ANKLE RECONSTRUCTION
Entity type:Organization
Organization Name:THE ORTHOPAEDIC CENTER FOR FOOT & ANKLE RECONSTRUCTION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-889-6580
Mailing Address - Street 1:100 KINGSLEY LN STE 300
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23505-4613
Mailing Address - Country:US
Mailing Address - Phone:757-889-6580
Mailing Address - Fax:757-889-6583
Practice Address - Street 1:100 KINGSLEY LN STE 300
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23505-4613
Practice Address - Country:US
Practice Address - Phone:757-889-6580
Practice Address - Fax:757-889-6583
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2011-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101044491174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010140811Medicaid
VAC09444Medicare PIN
VA00W310001Medicare PIN
VAE11839Medicare UPIN
VA5463150001Medicare NSC