Provider Demographics
NPI:1881766137
Name:FOOTCARE PODIATRY PC
Entity type:Organization
Organization Name:FOOTCARE PODIATRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:212-289-3388
Mailing Address - Street 1:309 E 104TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-5514
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:309 E 104TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-5514
Practice Address - Country:US
Practice Address - Phone:212-289-3388
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2010-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN005097174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01814768Medicaid
NYU47719Medicare UPIN
5016590001Medicare NSC
NY01814768Medicaid