=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821441635
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROFESSIONAL PODIATRY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/16/2016
-----------------------------------------------------
Last Update Date | 02/06/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 ORCHARD AVE SUITE B
-----------------------------------------------------
City | KENNETT SQUARE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19348-1812
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-388-8637
-----------------------------------------------------
Fax | 484-730-0060
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 43 STONERIDGE RD
-----------------------------------------------------
City | THORNTON
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19373-1042
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-357-6303
-----------------------------------------------------
Fax | 484-730-0060
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PODIATRIST/OWNER
-----------------------------------------------------
Name | DR. ERIN ELIZABETH KUTVOELGYI
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 610-357-6303
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0131X
-----------------------------------------------------
Taxonomy Name | Foot Surgery Podiatrist
-----------------------------------------------------
License Number | SC005540
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------