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General NPI Number Information
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NPI Number | 1861692402
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Entity Type | Organization
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Legal Business Name | MOBILE PODIATRIST, PC
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Dates
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Enumeration Date | 07/23/2007
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Last Update Date | 06/03/2011
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Provider Practice Location Address
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Address Line | 1558 VICTORIA CT
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City | GREENWOOD
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State | IN
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Zip | 46143-7884
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Country | US
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Telephone | 317-697-6536
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Fax | 317-859-2923
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Provider Business Mailing Address
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Address Line | 1558 VICTORIA CT
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City | GREENWOOD
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State | IN
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Zip | 46143-7884
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Country | US
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Telephone | 317-697-6536
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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. IRENE ERICA ROGE
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Credential | D.P.M.
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Telephone | 317-697-6536
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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 | 016-004848
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 213EP1101X
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Taxonomy Name | Primary Podiatric Medicine Podiatrist
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License Number | 07001009A
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License Number State | IN
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