MEDICARE: ABOITE PODIATRY ASSOCIATES 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	213ES0131X	Foot Surgery Podiatrist	07000636A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000103321	OTHER	IN	ANTHEM GROUP ID NUMBER

General Provider Information

NPI Number	:	1952523508
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ABOITE PODIATRY ASSOCIATES PC

Provider Business Mailing Address
First Line	:	7559 WEST JEFFERSON BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-4131
Country	:	US
Telephone Number	:	260-436-3579
Fax Number	:	260-459-0287

Provider Business Practice Location Address
First Line	:	7559 WEST JEFFERSON BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-4131
Country	:	US
Telephone Number	:	260-436-3579
Fax Number	:	260-459-0287

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. LYNN H STAFFORD
Credential	:	DPM
Telephone Number	:	260-436-3579

Provider Enumeration Date	:	05/03/2007
Last Update Date	:	10/08/2012

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