MEDICARE: BERKELEY COUNTY FOOT AND ANKLE CENTER 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	10391	WV

General Provider Information

NPI Number	:	1801061932
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BERKELEY COUNTY FOOT AND ANKLE CENTER LLC

Provider Business Mailing Address
First Line	:	3790 HEDGESVILLE RD
Second Line	:	SUITE O
City	:	HEDGESVILLE
State	:	WV
Zip	:	25427-6704
Country	:	US
Telephone Number	:	304-754-7130
Fax Number	:	717-762-1831

Provider Business Practice Location Address
First Line	:	3790 HEDGESVILLE ROAD
Second Line	:	SUITE O
City	:	HEDGESVILLE
State	:	WV
Zip	:	25427-6704
Country	:	US
Telephone Number	:	304-754-7130
Fax Number	:	717-762-1831

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JOHN S JACKO
Credential	:	D.P.M.
Telephone Number	:	304-754-7130

Provider Enumeration Date	:	04/29/2008
Last Update Date	:	05/07/2009

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