MEDICARE: PODIATRIST ON CALL, 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	213ES0103X	Foot & Ankle Surgery Podiatrist	PO3922	FL

General Provider Information

NPI Number	:	1295264224
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PODIATRIST ON CALL, LLC

Provider Business Mailing Address
First Line	:	1560 LANCASTER TER APT 206
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32204-4116
Country	:	US
Telephone Number	:	904-707-8769
Fax Number	:	844-663-5325

Provider Business Practice Location Address
First Line	:	2720 PARK ST STE 210
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32205-7645
Country	:	US
Telephone Number	:	904-707-8769
Fax Number	:	844-663-5325

Authorized Official
Title or Position	:	MANAGER
Name	:	DR. TROY ADAM HARRIS
Credential	:	DPM
Telephone Number	:	904-707-8769

Provider Enumeration Date	:	06/04/2017
Last Update Date	:	07/21/2022

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