Basic Information
| Provider Information | |||||||||
| NPI: | 1104861475 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HEALTHDRIVE PODIATRY GROUP, PA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HEALTHDRIVE PODIATRY GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 CROSSING BLVD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | FRAMINGHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 017025555 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6179646681 | ||||||||
| FaxNumber: | 6176300141 | ||||||||
| Practice Location | |||||||||
| Address1: | 4201 FM 1960 RD W | ||||||||
| Address2: | SUITE # 230 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770683414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2815371599 | ||||||||
| FaxNumber: | 2815371310 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2006 | ||||||||
| LastUpdateDate: | 01/02/2020 | ||||||||
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| AuthorizedOfficialLastName: | TRBOVICH | ||||||||
| AuthorizedOfficialFirstName: | MICHELE | ||||||||
| AuthorizedOfficialMiddleName: | LEE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/PRACTICE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2146970727 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 171674801 | 05 | TX | MEDICAID |