MEDICARE: MECKLENBURG FOOT & ANKLE ASSOCIATES AND DIABETIC FOOT CLINIC 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	332B00000X	Durable Medical Equipment & Medical Supplies
2	207XX0004X	Orthopaedic Foot and Ankle Surgery Physician
3	213ES0103X	Foot & Ankle Surgery Podiatrist	356	NC

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
2	0268L	OTHER	NC	GROUP NUMBER

General Provider Information

NPI Number	:	1881724227
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MECKLENBURG FOOT & ANKLE ASSOCIATES AND DIABETIC FOOT CLINIC PC

Provider Business Mailing Address
First Line	:	2115 E 7TH ST STE 102
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28204-3300
Country	:	US
Telephone Number	:	704-442-8433
Fax Number	:	704-817-9957

Provider Business Practice Location Address
First Line	:	2115 E 7TH ST STE 102
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28204-3300
Country	:	US
Telephone Number	:	704-442-8433
Fax Number	:	704-817-9957

Authorized Official
Title or Position	:	PRESIDENT, OWNER
Name	:	DR. ROBERT MITCHELL LIESMAN
Credential	:	DPM
Telephone Number	:	704-442-8433

Provider Enumeration Date	:	03/06/2007
Last Update Date	:	11/21/2018

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