Provider Demographics
NPI:1952514812
Name:EDMOND ANKLE & FOOT SPECIALISTS INC
Entity Type:Organization
Organization Name:EDMOND ANKLE & FOOT SPECIALISTS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:R
Authorized Official - Last Name:MAXWELL
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:405-340-9251
Mailing Address - Street 1:600 W 15TH
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013
Mailing Address - Country:US
Mailing Address - Phone:405-340-9251
Mailing Address - Fax:405-340-0686
Practice Address - Street 1:600 W 15TH
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013
Practice Address - Country:US
Practice Address - Phone:405-340-9251
Practice Address - Fax:405-340-0686
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK144213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
T79978Medicare UPIN
OKOKA101661Medicare PIN
0772980001Medicare NSC