MEDICARE: PORTLAND FOOT AND ANKLE, LLC

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	DP00332	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1225349566
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PORTLAND FOOT AND ANKLE, LLC

Provider Business Mailing Address
First Line	:	9370 SW GREENBURG RD STE A
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97223-5408
Country	:	US
Telephone Number	:	503-244-7894
Fax Number	:

Provider Business Practice Location Address
First Line	:	9370 SW GREENBURG RD STE A
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97223-5408
Country	:	US
Telephone Number	:	503-244-7894
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	STEPHEN HAYES
Credential	:	DPM
Telephone Number	:	503-244-7894

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

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