Healthcare Provider Details

I. General information

NPI: 1275854010
Provider Name (Legal Business Name): NORTHEAST FOOT & ANKLE ASSOCIATES, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2010
Last Update Date: 07/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

532 MAIN ST SUITE #2
MOOSIC PA
18507-1074
US

IV. Provider business mailing address

532 MAIN ST SUITE #2
MOOSIC PA
18507-1074
US

V. Phone/Fax

Practice location:
  • Phone: 570-457-6540
  • Fax: 570-457-6541
Mailing address:
  • Phone: 570-457-6540
  • Fax: 570-457-6541

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberSC004803L
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberSC004803-L
License Number StatePA

VIII. Authorized Official

Name: DR. JUSTINE M METCHO
Title or Position: OWNER
Credential: DPM
Phone: 570-457-6540