MEDICARE: THE FOOT AND ANKLE CLINIC 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	36002928	OH

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	:	1275667958
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE FOOT AND ANKLE CLINIC LLC

Provider Business Mailing Address
First Line	:	PO BOX 80690
Second Line	:
City	:	CANTON
State	:	OH
Zip	:	44708-0690
Country	:	US
Telephone Number	:	330-833-5692
Fax Number	:	330-833-6085

Provider Business Practice Location Address
First Line	:	4330 W 150TH ST
Second Line	:	220
City	:	CLEVELAND
State	:	OH
Zip	:	44135-1362
Country	:	US
Telephone Number	:	216-227-2194
Fax Number	:	216-227-2196

Authorized Official
Title or Position	:	OWNER
Name	:	KRISTINA M KOVACH
Credential	:	DPM
Telephone Number	:	216-227-2194

Provider Enumeration Date	:	03/15/2007
Last Update Date	:	01/24/2008

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Directions to “THE FOOT AND ANKLE CLINIC LLC ” Practice Location

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