Healthcare Provider Details

I. General information

NPI: 1437339868
Provider Name (Legal Business Name): NORTH ATLANTIC PODIATRY, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2007
Last Update Date: 07/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

83 SHERIDAN AVE
MEDFORD MA
02155-4042
US

IV. Provider business mailing address

83 SHERIDAN AVE
MEDFORD MA
02155-4042
US

V. Phone/Fax

Practice location:
  • Phone: 978-458-4011
  • Fax: 978-458-4020
Mailing address:
  • Phone: 978-458-4011
  • Fax: 978-458-4020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: WAYNE MCCULLOUGH
Title or Position: DPM
Credential:
Phone: 978-458-4011