=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508049123
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHILADELPHIA FOOT AND ANKLE PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/06/2007
-----------------------------------------------------
Last Update Date | 12/06/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2075 E ALLEGHENY AVE
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19134-3832
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-425-3700
-----------------------------------------------------
Fax | 215-425-5233
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2075 E ALLEGHENY AVE
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19134-3832
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-425-3700
-----------------------------------------------------
Fax | 215-425-5233
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | DR. LARRY GOSS
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 215-425-3700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | SC004111L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------