Healthcare Provider Details

I. General information

NPI: 1457512949
Provider Name (Legal Business Name): STARK COUNTY FOOT & ANKLE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2008
Last Update Date: 06/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4503 FULTON DR NW
CANTON OH
44718-2331
US

IV. Provider business mailing address

4503 FULTON DR NW
CANTON OH
44718-2331
US

V. Phone/Fax

Practice location:
  • Phone: 330-956-4857
  • Fax:
Mailing address:
  • Phone: 330-956-4857
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberOH36002987
License Number StateOH

VIII. Authorized Official

Name: STEVEN D GROSS
Title or Position: OWNER
Credential: D.P.M.
Phone: 330-837-7715