Provider Demographics
NPI:1912955162
Name:MADISON LEE PODIATRY INC
Entity Type:Organization
Organization Name:MADISON LEE PODIATRY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:PORTNOW
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:216-491-9902
Mailing Address - Street 1:3691 LEE RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SHAKER HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44120-5145
Mailing Address - Country:US
Mailing Address - Phone:216-491-9902
Mailing Address - Fax:216-491-8151
Practice Address - Street 1:3691 LEE RD
Practice Address - Street 2:SUITE 102
Practice Address - City:SHAKER HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44120-5145
Practice Address - Country:US
Practice Address - Phone:216-491-9902
Practice Address - Fax:216-491-8151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-04
Last Update Date:2010-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2576213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2245814Medicaid
OH6318540002Medicare NSC
OHT96121Medicare UPIN
OH9282764Medicare PIN
OH9282761Medicare PIN
OH2245814Medicaid