Provider Demographics
NPI:1982763439
Name:MEDFORD FOOT SPECIALISTS LLC
Entity Type:Organization
Organization Name:MEDFORD FOOT SPECIALISTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:L
Authorized Official - Last Name:KOWALEWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-753-0913
Mailing Address - Street 1:128 ROUTE 70
Mailing Address - Street 2:SUITE 14
Mailing Address - City:MEDFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08055-2371
Mailing Address - Country:US
Mailing Address - Phone:609-714-3434
Mailing Address - Fax:609-714-1933
Practice Address - Street 1:128 ROUTE 70
Practice Address - Street 2:SUITE 14
Practice Address - City:MEDFORD
Practice Address - State:NJ
Practice Address - Zip Code:08055-2371
Practice Address - Country:US
Practice Address - Phone:609-714-3434
Practice Address - Fax:609-714-1933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7899700Medicaid
NJ5134310001Medicare NSC
NJ051760Medicare ID - Type Unspecified
DA8191Medicare PIN