Healthcare Provider Details

I. General information

NPI: 1083348791
Provider Name (Legal Business Name): PLYMOUTH PODIATRY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2022
Last Update Date: 11/08/2023
Certification Date: 11/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

68 CAMP ST STE 2
HYANNIS MA
02601-3048
US

IV. Provider business mailing address

116 COURT ST STE 3
PLYMOUTH MA
02360-8710
US

V. Phone/Fax

Practice location:
  • Phone: 774-470-4507
  • Fax: 774-810-7189
Mailing address:
  • Phone: 508-747-1973
  • Fax: 508-747-5392

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL J. SKONIECZNY
Title or Position: OWNER PROVIDER
Credential:
Phone: 508-747-1973