MEDICARE: PODIATRIC SURGI CENTER INC

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	261QA1903X	Ambulatory Surgical Clinic/Center		OH

General Provider Information

NPI Number	:	1942206677
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PODIATRIC SURGI CENTER INC

Provider Business Mailing Address
First Line	:	64 EXECUTIVE DR
Second Line	:
City	:	NORWALK
State	:	OH
Zip	:	44857-9568
Country	:	US
Telephone Number	:	419-663-3338
Fax Number	:

Provider Business Practice Location Address
First Line	:	64 EXECUTIVE DR
Second Line	:
City	:	NORWALK
State	:	OH
Zip	:	44857-9568
Country	:	US
Telephone Number	:	419-663-3338
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JAMES REVELAS
Credential	:	D.P.M.
Telephone Number	:	419-663-3338

Provider Enumeration Date	:	06/27/2005
Last Update Date	:	07/21/2022

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