Healthcare Provider Details

I. General information

NPI: 1821391434
Provider Name (Legal Business Name): NORTHEAST FOOT AND ANKLE SPECIALISTS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2010
Last Update Date: 02/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9922 ROOSEVELT BLVD
PHILADELPHIA PA
19115-1705
US

IV. Provider business mailing address

9922 ROOSEVELT BLVD
PHILADELPHIA PA
19115-1705
US

V. Phone/Fax

Practice location:
  • Phone: 215-464-2000
  • Fax: 215-464-6046
Mailing address:
  • Phone: 215-464-2000
  • Fax: 215-464-6046

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License NumberSC-009751
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberSC-009751
License Number StatePA

VIII. Authorized Official

Name: DR. ALBERT MOSHEYEV
Title or Position: PRESIDENT
Credential: DPM
Phone: 215-464-2000