Healthcare Provider Details

I. General information

NPI: 1356588917
Provider Name (Legal Business Name): ADVANCED FEET AND ANKLE CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2009
Last Update Date: 08/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2477 HIGHWAY 516
OLD BRIDGE NJ
08857-4603
US

IV. Provider business mailing address

2477 HIGHWAY 516
OLD BRIDGE NJ
08857-4603
US

V. Phone/Fax

Practice location:
  • Phone: 732-679-4330
  • Fax: 732-679-4777
Mailing address:
  • Phone: 732-679-4330
  • Fax: 732-679-4777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JASON M. GROSSMAN
Title or Position: OWNER
Credential: DPM
Phone: 732-679-4330