Healthcare Provider Details

I. General information

NPI: 1619954906
Provider Name (Legal Business Name): ACHILLES FOOT & ANKLE SURGERY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2005
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2108 LUMBER AVE STE 2
WHEELING WV
26003-5350
US

IV. Provider business mailing address

2108 LUMBER AVE STE 2
WHEELING WV
26003-5350
US

V. Phone/Fax

Practice location:
  • Phone: 304-243-8799
  • Fax: 740-633-4716
Mailing address:
  • Phone: 304-243-8799
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number00239
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number36002569B
License Number StateOH

VIII. Authorized Official

Name: BRUCE GARY BLANK
Title or Position: PRESIDENT
Credential: DPM
Phone: 740-633-4188