MEDICARE: FOOT & ANKLE ASSOCIATES OF THE TRIAD, PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213E00000X	Podiatrist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	021WJ	OTHER	NC	BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063641710
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOOT & ANKLE ASSOCIATES OF THE TRIAD, PA

Provider Business Mailing Address
First Line	:	3641 WESTGATE CENTER CIR
Second Line	:	SUITE A
City	:	WINSTON SALEM
State	:	NC
Zip	:	27103-2936
Country	:	US
Telephone Number	:	336-774-4021
Fax Number	:	336-774-4024

Provider Business Practice Location Address
First Line	:	3641 WESTGATE CENTER CIR
Second Line	:	SUITE A
City	:	WINSTON SALEM
State	:	NC
Zip	:	27103-2936
Country	:	US
Telephone Number	:	336-774-4021
Fax Number	:	336-774-4024

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. THURMOND ERIC SICELOFF
Credential	:	DPM
Telephone Number	:	336-774-4021

Provider Enumeration Date	:	07/02/2009
Last Update Date	:	01/07/2010

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