Healthcare Provider Details

I. General information

NPI: 1053835827
Provider Name (Legal Business Name): PRIME FOOT AND ANKLE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2017
Last Update Date: 08/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

817 MERRIMACK ST
LOWELL MA
01854-3571
US

IV. Provider business mailing address

817 MERRIMACK ST
LOWELL MA
01854-3571
US

V. Phone/Fax

Practice location:
  • Phone: 508-667-8200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number2439
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number2439
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number2439
License Number StateMA

VIII. Authorized Official

Name: PAUL GEORGES
Title or Position: DPM
Credential:
Phone: 508-667-8200