=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942295001
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RICHMOND FOOT & ANKLE CARE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2005
-----------------------------------------------------
Last Update Date | 12/05/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 464 RICHMOND RD SUITE 201
-----------------------------------------------------
City | RICHMOND HEIGHTS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44143-2704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-481-6654
-----------------------------------------------------
Fax | 216-481-3185
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 464 RICHMOND RD SUITE 201
-----------------------------------------------------
City | RICHMOND HEIGHTS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44143-2704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-481-6654
-----------------------------------------------------
Fax | 216-481-3185
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | DR. VADIM GLUKH
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 216-481-6654
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | 36003112
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------