=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902011125
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTH EAST FOOT CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/11/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 90 E MAIN ST SUITE 3
-----------------------------------------------------
City | NORTH EAST
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16428-1319
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-725-2715
-----------------------------------------------------
Fax | 814-725-5186
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 90 E MAIN ST SUITE 3
-----------------------------------------------------
City | NORTH EAST
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16428-1319
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-725-2715
-----------------------------------------------------
Fax | 814-725-5186
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MORGAN TIMOTHY HOLMES
-----------------------------------------------------
Credential | D.P.M.
-----------------------------------------------------
Telephone | 814-725-2715
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0131X
-----------------------------------------------------
Taxonomy Name | Foot Surgery Podiatrist
-----------------------------------------------------
License Number | SC003377L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------