Healthcare Provider Details

I. General information

NPI: 1699172908
Provider Name (Legal Business Name): OHIO PODIATRIC PHYSICIANS AND SURGEONS GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2014
Last Update Date: 12/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 GREENVILLE ORTHOPEDIC CTR
GREENVILLE PA
16125-1210
US

IV. Provider business mailing address

8175 MARKET ST
YOUNGSTOWN OH
44512-6244
US

V. Phone/Fax

Practice location:
  • Phone: 724-588-3770
  • Fax: 724-588-3774
Mailing address:
  • Phone: 330-629-8800
  • Fax: 330-758-4914

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: LAWRENCE DIDOMENICO
Title or Position: MANAGING PARTNER
Credential: DPM
Phone: 330-629-8800