Provider Demographics
NPI:1801013115
Name:AMBULATORY FOOT CARE CENTER P C
Entity type:Organization
Organization Name:AMBULATORY FOOT CARE CENTER P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:CANAVAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:434-799-9430
Mailing Address - Street 1:789 PINEY FOREST RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24540-2877
Mailing Address - Country:US
Mailing Address - Phone:434-799-9430
Mailing Address - Fax:434-792-8438
Practice Address - Street 1:789 PINEY FOREST RD
Practice Address - Street 2:SUITE B
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24540-2877
Practice Address - Country:US
Practice Address - Phone:434-799-9430
Practice Address - Fax:434-792-8438
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2013-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103 000583213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1891739991OtherDR MICHAEL CANAVAN NPI #
VA009301631Medicaid
VA46126OtherOPTIMA
NC890803NMedicaid
VA1891739991OtherMUTUAL OF OMAHA
C02497OtherMEDICARE PTAN
VACF9579OtherRET RAILROAD MCRE
VA066476OtherANTHEM
C02497OtherMEDICARE PTAN
C02497OtherMEDICARE PTAN