MEDICARE: WILLAMETTE VALLEY FOOT & ANKLE CENTER PC

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	261QP1100X	Podiatric Clinic/Center

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	:	1639158611
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILLAMETTE VALLEY FOOT & ANKLE CENTER PC

Provider Business Mailing Address
First Line	:	212 NE NORTON LN
Second Line	:
City	:	MCMINNVILLE
State	:	OR
Zip	:	97128-8470
Country	:	US
Telephone Number	:	503-435-0130
Fax Number	:	503-435-0145

Provider Business Practice Location Address
First Line	:	212 NE NORTON LN
Second Line	:
City	:	MCMINNVILLE
State	:	OR
Zip	:	97128-8470
Country	:	US
Telephone Number	:	503-435-0130
Fax Number	:	503-435-0145

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JEFFREY R RUSSO
Credential	:	DPM
Telephone Number	:	503-435-0130

Provider Enumeration Date	:	01/10/2006
Last Update Date	:	02/21/2008

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Directions to “WILLAMETTE VALLEY FOOT & ANKLE CENTER PC ” Practice Location

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