MEDICARE: WHITE MOUNTAIN FOOT AND ANKLE CARE CENTER PLLC

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	640	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1508058249
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WHITE MOUNTAIN FOOT AND ANKLE CARE CENTER PLLC

Provider Business Mailing Address
First Line	:	PO BOX 39
Second Line	:
City	:	OVERGAARD
State	:	AZ
Zip	:	85933-0039
Country	:	US
Telephone Number	:	928-532-1122
Fax Number	:	928-532-1124

Provider Business Practice Location Address
First Line	:	5448 WHITE MOUNTAIN BLVD
Second Line	:	SUITE 270
City	:	LAKESIDE
State	:	AZ
Zip	:	85929-5739
Country	:	US
Telephone Number	:	928-532-1122
Fax Number	:	928-532-1124

Authorized Official
Title or Position	:	PRESIDENT
Name	:	H RYAN HALL
Credential	:	DPM
Telephone Number	:	928-367-3701

Provider Enumeration Date	:	08/16/2007
Last Update Date	:	12/12/2008

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