=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053603282
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAUMEE BAY FOOT & ANKLE SPECIALISTS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/05/2011
-----------------------------------------------------
Last Update Date | 11/04/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3515 NAVARRE AVE
-----------------------------------------------------
City | OREGON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43616-3429
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-304-0283
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3515 NAVARRE AVE
-----------------------------------------------------
City | OREGON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43616-3429
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-304-0283
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PHYSICIAN
-----------------------------------------------------
Name | DR. JOSHUA CHARLES MORRIS
-----------------------------------------------------
Credential | D.P.M.
-----------------------------------------------------
Telephone | 419-304-0283
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | 003561
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------