Basic Information
Provider Information
NPI: 1326220674
EntityType: 2
ReplacementNPI:  
OrganizationName: HEALTHDRIVE PODIATRY GROUP, PC
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: HEALTHDRIVE PODIATRY GROUP
OtherOrganizationType: 3
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 100 CROSSING BLVD
Address2: SUITE 300
City: FRAMINGHAM
State: MA
PostalCode: 017025555
CountryCode: US
TelephoneNumber: 6179646681
FaxNumber: 3396862561
Practice Location
Address1: 12 PENNS TRAIL
Address2: SUITE 154
City: NEWTOWN
State: PA
PostalCode: 189403438
CountryCode: US
TelephoneNumber: 2156753005
FaxNumber: 8886620859
Other Information
ProviderEnumerationDate: 11/28/2007
LastUpdateDate: 01/02/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: ABBOUD
AuthorizedOfficialFirstName: SHADI
AuthorizedOfficialMiddleName: ADIB
AuthorizedOfficialTitleorPosition: TREASURER/PRACTICE DIRECTOR
AuthorizedOfficialTelephone: 8572550486
IsSoleProprietor:  
IsOrganizationSubpart: Y
ParentOrganizationLBN: HEALTHDRIVE PODIATRY GROUP, PC
AuthorizedOfficialNamePrefix: DR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: DPM
NPICertificationDate: 01/02/2020

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
335E00000X  N SuppliersProsthetic/Orthotic Supplier 
213E00000X  Y193400000X SINGLE SPECIALTY GROUPPodiatric Medicine & Surgery Service ProvidersPodiatrist 

No ID Information.


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