Provider Demographics
NPI:1801165618
Name:ELITE FOOT AND ANKLE LLC
Entity type:Organization
Organization Name:ELITE FOOT AND ANKLE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TREVOR
Authorized Official - Middle Name:A
Authorized Official - Last Name:DAVY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:614-539-4964
Mailing Address - Street 1:6024 HOOVER RD
Mailing Address - Street 2:SUITE F
Mailing Address - City:GROVE CITY
Mailing Address - State:OH
Mailing Address - Zip Code:43123-8133
Mailing Address - Country:US
Mailing Address - Phone:614-539-4964
Mailing Address - Fax:614-539-4609
Practice Address - Street 1:6024 HOOVER RD
Practice Address - Street 2:SUITE F
Practice Address - City:GROVE CITY
Practice Address - State:OH
Practice Address - Zip Code:43123-8133
Practice Address - Country:US
Practice Address - Phone:614-539-4964
Practice Address - Fax:614-539-4609
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-22
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36-003396213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0058765Medicaid
OHH086510Medicare PIN
OH0058765Medicaid