=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376619924
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCED MEDICAL FOOTCARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/27/2006
-----------------------------------------------------
Last Update Date | 09/10/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1817 BLACK ROCK TURNPIKE
-----------------------------------------------------
City | FAIRFIELD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06825-3546
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-330-8080
-----------------------------------------------------
Fax | 203-334-6924
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1817 BLACK ROCK TURNPIKE
-----------------------------------------------------
City | FAIRFIELD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06825-3546
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-330-8080
-----------------------------------------------------
Fax | 203-334-6924
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER
-----------------------------------------------------
Name | CAROL A CALLAHAN
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 203-330-8080
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------