Provider Demographics
NPI:1952425498
Name:HAYCOCK FOOT AND ANKLE CENTER, LLC
Entity type:Organization
Organization Name:HAYCOCK FOOT AND ANKLE CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DARRYL
Authorized Official - Middle Name:MITCHELL
Authorized Official - Last Name:HAYCOCK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:419-228-3338
Mailing Address - Street 1:2311 BATON ROUGE
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45805-1129
Mailing Address - Country:US
Mailing Address - Phone:419-228-3338
Mailing Address - Fax:419-228-3334
Practice Address - Street 1:2311 BATON ROUGE
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45805-1129
Practice Address - Country:US
Practice Address - Phone:419-228-3338
Practice Address - Fax:419-228-3334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36002946213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2094951Medicaid
OH2094951Medicaid
OHHA0859395Medicare ID - Type UnspecifiedMEDICARE INDIVIDUAL
OHU72571Medicare UPIN
OH5654010001Medicare NSC