Healthcare Provider Details

I. General information

NPI: 1669428991
Provider Name (Legal Business Name): SUPPAN FOOT AND ANKLE CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 08/26/2020
Certification Date: 08/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1710 PARADISE RD
ORRVILLE OH
44667-9418
US

IV. Provider business mailing address

6200 PLEASANT AVE STE 3
FAIRFIELD OH
45014-4671
US

V. Phone/Fax

Practice location:
  • Phone: 330-682-6070
  • Fax: 330-684-2822
Mailing address:
  • Phone: 330-682-6070
  • Fax: 330-684-2822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JASON NORBERT SUPPAN
Title or Position: PRESIDENT
Credential: DPM
Phone: 330-642-6070