MEDICARE: NORTHPORT PODIATRY 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	213ES0103X	Foot & Ankle Surgery Podiatrist	N005219	NY

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	W3P441	OTHER	NY	MEDICARE PTAN
2	480034015	OTHER		RR MEDICARE

Other Identifiers

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

General Provider Information

NPI Number	:	1679745103
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHPORT PODIATRY PC

Provider Business Mailing Address
First Line	:	1032 FORT SALONGA RD
Second Line	:
City	:	NORTHPORT
State	:	NY
Zip	:	11768-2208
Country	:	US
Telephone Number	:	631-754-3338
Fax Number	:	631-754-3367

Provider Business Practice Location Address
First Line	:	1032 FORT SALONGA RD
Second Line	:
City	:	NORTHPORT
State	:	NY
Zip	:	11768-2208
Country	:	US
Telephone Number	:	631-754-3338
Fax Number	:	631-754-3367

Authorized Official
Title or Position	:	OWNER/PODIATRIST
Name	:	MRS. DENISE G RAIO
Credential	:	D.P.M.
Telephone Number	:	631-754-3338

Provider Enumeration Date	:	03/25/2008
Last Update Date	:	02/24/2010

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Directions to “NORTHPORT PODIATRY PC ” Practice Location

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