Healthcare Provider Details

I. General information

NPI: 1013204692
Provider Name (Legal Business Name): CENTER FOR ADVANCED FOOT & ANKLE SURGERY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2011
Last Update Date: 07/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 BOWLES AVE SUITE 123
FENTON MO
63026-2395
US

IV. Provider business mailing address

PO BOX 771754
SAINT LOUIS MO
63177-1754
US

V. Phone/Fax

Practice location:
  • Phone: 314-991-3668
  • Fax: 314-991-3665
Mailing address:
  • Phone: 314-989-0300
  • Fax:

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 Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: JOHN J HOLTZMAN
Title or Position: DPM/PARTNER
Credential: DPM
Phone: 314-991-3668