Provider Demographics
NPI:1932371374
Name:SPA PODIATRY, PC
Entity Type:Organization
Organization Name:SPA PODIATRY, PC
Other - Org Name:MALTA FOOT SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY/PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:MONGIOVI
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:518-899-3338
Mailing Address - Street 1:3 HEMPHILL PL STE 111
Mailing Address - Street 2:
Mailing Address - City:MALTA
Mailing Address - State:NY
Mailing Address - Zip Code:12020-4420
Mailing Address - Country:US
Mailing Address - Phone:518-899-3338
Mailing Address - Fax:518-899-5025
Practice Address - Street 1:3 HEMPHILL PL STE 111
Practice Address - Street 2:
Practice Address - City:MALTA
Practice Address - State:NY
Practice Address - Zip Code:12020-4420
Practice Address - Country:US
Practice Address - Phone:518-899-3338
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-26
Last Update Date:2013-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN004782213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRB8170OtherRUSSELL J MONGIOVI, DPM
NYRB8171OtherJOYCE M SENICK, DPM
NY6119720001Medicare NSC
NYBA1460Medicare PIN