=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114047438
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCED FOOT AND ANKLE CLINICS PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/30/2007
-----------------------------------------------------
Last Update Date | 01/17/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 903 SE 22ND ST STE 1
-----------------------------------------------------
City | BENTONVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72712-4196
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-271-5353
-----------------------------------------------------
Fax | 479-254-0698
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 903 SE 22ND ST STE 1
-----------------------------------------------------
City | BENTONVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72712-4196
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-271-5353
-----------------------------------------------------
Fax | 479-254-0698
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PODIATRIST
-----------------------------------------------------
Name | DR. STEPHEN SAMUEL PIROTTA
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 479-271-5353
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | 133
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------