MEDICARE: CORAM PODIATRY PLLC

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	213E00000X	Podiatrist

General Provider Information

NPI Number	:	1902520810
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CORAM PODIATRY PLLC

Provider Business Mailing Address
First Line	:	100 MIDDLE COUNTRY RD
Second Line	:
City	:	CORAM
State	:	NY
Zip	:	11727-4412
Country	:	US
Telephone Number	:	631-696-9636
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 MIDDLE COUNTRY RD
Second Line	:
City	:	CORAM
State	:	NY
Zip	:	11727-4412
Country	:	US
Telephone Number	:	631-696-9636
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING MANAGER
Name	:	TAMMY CAMPBELL
Credential	:
Telephone Number	:	239-257-7290

Provider Enumeration Date	:	10/04/2022
Last Update Date	:	10/04/2022

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Directions to “CORAM PODIATRY PLLC ” Practice Location

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