Healthcare Provider Details

I. General information

NPI: 1144626482
Provider Name (Legal Business Name): OHIO PODIATRIC PHYSICIANS AND SURGEONS GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2014
Last Update Date: 11/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 E SMITH RD
MEDINA OH
44256-2637
US

IV. Provider business mailing address

535 E SMITH RD
MEDINA OH
44256-2637
US

V. Phone/Fax

Practice location:
  • Phone: 330-725-7075
  • Fax: 330-725-3988
Mailing address:
  • Phone: 330-725-7075
  • Fax: 330-725-3988

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number36-002284
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number36-002284
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number36-002284
License Number StateOH

VIII. Authorized Official

Name: DR. GARY L. UNSDORFER
Title or Position: PHYSICIAN
Credential: D.P.M.
Phone: 330-725-7075