Healthcare Provider Details

I. General information

NPI: 1386399004
Provider Name (Legal Business Name): MIDWEST FOOT AND ANKLE CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2022
Last Update Date: 02/22/2022
Certification Date: 02/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1035 W WAYNE ST
PAULDING OH
45879-1544
US

IV. Provider business mailing address

208 COLUMBUS ST STE 200
HICKSVILLE OH
43526-1250
US

V. Phone/Fax

Practice location:
  • Phone: 419-799-1180
  • Fax:
Mailing address:
  • Phone: 419-799-1180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number StateNULL

VIII. Authorized Official

Name: NITIE I SROA
Title or Position: OWNER
Credential: DPM
Phone: 419-799-1180