MEDICARE: ADVANCED FOOT & 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	07000941A	IN

General Provider Information

NPI Number	:	1972875854
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADVANCED FOOT & ANKLE CENTER LLC

Provider Business Mailing Address
First Line	:	27 ASPEN RD
Second Line	:
City	:	PORTAGE
State	:	IN
Zip	:	46368-1027
Country	:	US
Telephone Number	:	219-405-3775
Fax Number	:	219-405-3775

Provider Business Practice Location Address
First Line	:	111 BOYD CIR
Second Line	:
City	:	MICHIGAN CITY
State	:	IN
Zip	:	46360-7016
Country	:	US
Telephone Number	:	219-405-3775
Fax Number	:	219-405-3775

Authorized Official
Title or Position	:	DOCTOR
Name	:	CYNTHIA GRUNDY
Credential	:	DPM
Telephone Number	:	219-405-3775

Provider Enumeration Date	:	02/07/2012
Last Update Date	:	09/12/2019

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