Healthcare Provider Details

I. General information

NPI: 1730196601
Provider Name (Legal Business Name): BRADFORD FOOT AND ANKLE SPECIALTIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 04/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1786 GOLDEN MILE RD SUITE 1
TOWANDA PA
18848-9733
US

IV. Provider business mailing address

PO BOX 376
WYSOX PA
18854-0376
US

V. Phone/Fax

Practice location:
  • Phone: 570-265-7700
  • Fax: 570-268-4266
Mailing address:
  • Phone: 570-265-7700
  • Fax: 570-268-4266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberSC003249L
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1025528480001
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer
# 2
Identifier206545
Identifier TypeOTHER
Identifier State
Identifier IssuerMEDICARE PTAN

VIII. Authorized Official

Name: DR. TIMOTHY M KUMP
Title or Position: OWNER
Credential: DPM
Phone: 570-265-7700