=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174968218
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FOOT AND ANKLE CLINIC OF THE VIRGINIAS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/02/2013
-----------------------------------------------------
Last Update Date | 02/26/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5504 MACCORKLE AVE SE
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25304-2320
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-487-9442
-----------------------------------------------------
Fax | 866-420-4578
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 825159
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19182-5159
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-487-9442
-----------------------------------------------------
Fax | 866-420-4578
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | TIMOTHY DONATELLI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 304-487-9442
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------