=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932297264
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EASTOVER FOOT & ANKLE PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/11/2006
-----------------------------------------------------
Last Update Date | 10/02/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 428 N. TRADE STREET SUITE 100
-----------------------------------------------------
City | MATTHEWS
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28105-5017
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-841-4000
-----------------------------------------------------
Fax | 704-841-4338
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1539
-----------------------------------------------------
City | MATTHEWS
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28106-1539
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-841-4000
-----------------------------------------------------
Fax | 704-841-4338
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | RONALD VICTOR FUTERMAN
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 704-841-4000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | 200001392347
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------