MEDICARE: BROADWAY FOOT & ANKLE CLINIC, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213ES0103X	Foot & Ankle Surgery Podiatrist	DP00315	OR
2	213ES0103X	Foot & Ankle Surgery Podiatrist	DP00244	OR
3	213ES0103X	Foot & Ankle Surgery Podiatrist	DP00179	OR

General Provider Information

NPI Number	:	1457498438
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BROADWAY FOOT & ANKLE CLINIC, PC

Provider Business Mailing Address
First Line	:	3508 NE BROADWAY ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97232-1821
Country	:	US
Telephone Number	:	503-282-8777
Fax Number	:	503-282-8853

Provider Business Practice Location Address
First Line	:	3508 NE BROADWAY ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97232-1821
Country	:	US
Telephone Number	:	503-282-8777
Fax Number	:	503-282-8853

Authorized Official
Title or Position	:	DPM
Name	:	ELLIOT MICHAEL
Credential	:	DPM
Telephone Number	:	503-648-2200

Provider Enumeration Date	:	01/31/2007
Last Update Date	:	08/07/2009

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