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General NPI Number Information
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NPI Number | 1821185455
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Entity Type | Organization
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Legal Business Name | MEDICAL CENTER WEST PODIATRY ASSOCIATES, INC.
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Dates
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Enumeration Date | 10/06/2006
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Last Update Date | 03/25/2008
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Provider Practice Location Address
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Address Line | 488 PLEASANT ST
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City | WORCESTER
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State | MA
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Zip | 01609-1857
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Country | US
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Telephone | 508-755-9573
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Fax |
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Provider Business Mailing Address
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Address Line | 126 BUSHY LN
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City | RUTLAND
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State | MA
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Zip | 01543-2025
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Country | US
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Telephone | 508-886-6280
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JONATHAN F. KETCHUM
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Credential | D.P.M.
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Telephone | 508-755-9573
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213EP1101X
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Taxonomy Name | Primary Podiatric Medicine Podiatrist
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License Number | 2087
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License Number State | MA
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