MEDICARE: MADISON LEE PODIATRY INC

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	213E00000X	Podiatrist	2576	OH

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	:	1912955162
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MADISON LEE PODIATRY INC

Provider Business Mailing Address
First Line	:	3691 LEE RD
Second Line	:	SUITE 102
City	:	SHAKER HEIGHTS
State	:	OH
Zip	:	44120-5145
Country	:	US
Telephone Number	:	216-491-9902
Fax Number	:	216-491-8151

Provider Business Practice Location Address
First Line	:	3691 LEE RD
Second Line	:	SUITE 102
City	:	SHAKER HEIGHTS
State	:	OH
Zip	:	44120-5145
Country	:	US
Telephone Number	:	216-491-9902
Fax Number	:	216-491-8151

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ROBERT THOMAS PORTNOW
Credential	:	DPM
Telephone Number	:	216-491-9902

Provider Enumeration Date	:	05/04/2006
Last Update Date	:	06/21/2010

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Practice Location Address:

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1063817955 — MS. MARIE WHITSON M.A., LCDCIII, ICADC
Practice Location Address:

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1316749229 — DEMIKO CHEVALLIER RN
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