=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285072827
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FIELDS FOOT AND ANKLE CORP.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/05/2013
-----------------------------------------------------
Last Update Date | 06/05/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3112 WEBSTER AVE
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10467-4926
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-655-3410
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3112 WEBSTER AVE
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10467-4926
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | RICHARD FIELDS
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 310-383-7707
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | 65006558
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------