Healthcare Provider Details

I. General information

NPI: 1386807543
Provider Name (Legal Business Name): FOOTSOURCE MD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2008
Last Update Date: 12/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 POLARIS PKWY SUITE 2000
WESTERVILLE OH
43082-7989
US

IV. Provider business mailing address

300 POLARIS PKWY SUITE 2000
WESTERVILLE OH
43082-7989
US

V. Phone/Fax

Practice location:
  • Phone: 614-895-8747
  • Fax: 614-882-6503
Mailing address:
  • Phone: 614-895-8747
  • Fax: 614-882-6503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number25-901188
License Number StateOH

VIII. Authorized Official

Name: DR. THOMAS H LEE
Title or Position: PRESIDENT
Credential: MD
Phone: 614-895-8747