Healthcare Provider Details

I. General information

NPI: 1508264680
Provider Name (Legal Business Name): OHIO PODIATRIC PHYSICIANS AND SURGEONS GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2014
Last Update Date: 12/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5757 MONCLOVA RD SUITE 5
MAUMEE OH
43537-1863
US

IV. Provider business mailing address

5757 MONCLOVA RD SUITE 5
MAUMEE OH
43537-1863
US

V. Phone/Fax

Practice location:
  • Phone: 419-893-5757
  • Fax: 419-893-5399
Mailing address:
  • Phone: 419-893-5757
  • Fax: 419-893-5399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number36003428
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number36003428
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number36003428
License Number StateOH

VIII. Authorized Official

Name: BEAU GREGORY BORTEL
Title or Position: PHYSICIAN
Credential: DPM
Phone: 419-893-5757