Provider Demographics
NPI:1932191996
Name:MOUNTAIN CREST FOOT AND ANKLE PA
Entity Type:Organization
Organization Name:MOUNTAIN CREST FOOT AND ANKLE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:ROGER
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:208-528-8700
Mailing Address - Street 1:3652 WASHINGTON PKWY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7573
Mailing Address - Country:US
Mailing Address - Phone:208-528-8700
Mailing Address - Fax:208-528-2802
Practice Address - Street 1:3652 WASHINGTON PKWY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7573
Practice Address - Country:US
Practice Address - Phone:208-528-8700
Practice Address - Fax:208-528-2802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-16
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP-169213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806462800Medicaid
ID806462800Medicaid
ID4590880001Medicare NSC
ID1350919Medicare ID - Type Unspecified