Healthcare Provider Details

I. General information

NPI: 1710914379
Provider Name (Legal Business Name): THE FOOT GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 01/08/2020
Certification Date: 01/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

162 A MANSFIELD AVE
WILLIMANTIC CT
06226
US

IV. Provider business mailing address

162 A MANSFIELD AVE
WILLIMANTIC CT
06226
US

V. Phone/Fax

Practice location:
  • Phone: 860-456-4250
  • Fax: 860-456-3745
Mailing address:
  • Phone: 860-456-4250
  • Fax: 860-456-3745

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number650
License Number StateCT

VIII. Authorized Official

Name: DR. MICHAEL SCANLON
Title or Position: PRESIDENT
Credential: DPM
Phone: 860-456-4250