Healthcare Provider Details

I. General information

NPI: 1174739940
Provider Name (Legal Business Name): NORTHEAST FAMILY FOOT CARE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 11/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9892 BUSTLETON AVE SUITE 303
PHILADELPHIA PA
19115-2184
US

IV. Provider business mailing address

9892 BUSTLETON AVE SUITE 303
PHILADELPHIA PA
19115-2184
US

V. Phone/Fax

Practice location:
  • Phone: 215-673-3200
  • Fax: 215-673-3884
Mailing address:
  • Phone: 215-673-3200
  • Fax: 215-673-3884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberSC004123-L
License Number StatePA

VIII. Authorized Official

Name: DR. DONNA G. MYERS
Title or Position: OWNER
Credential: DPM
Phone: 215-673-3200