Basic Information
Provider Information | |||||||||
NPI: | 1689613598 | ||||||||
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: | 100 CROSSING BLVD | ||||||||
Address2: | SUITE 300 | ||||||||
City: | FRAMINGHAM | ||||||||
State: | MA | ||||||||
PostalCode: | 017025555 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6179646681 | ||||||||
FaxNumber: | 3396862561 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/06/2006 | ||||||||
LastUpdateDate: | 06/23/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ALTOMONTE | ||||||||
AuthorizedOfficialFirstName: | RIYA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT/PRACTICE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 8572550486 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | DPM | ||||||||
NPICertificationDate: | 06/23/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 335E00000X |   |   | N |   | Suppliers | Prosthetic/Orthotic Supplier |   | 213E00000X |   |   | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |   |
ID Information
ID | Type | State | Issuer | Description | CI9828 | 01 | MA | MEDICARE RAILROAD | OTHER | 41738600 | 05 | WI |   | MEDICAID | 9769536 | 05 | MA |   | MEDICAID | 423718800 | 05 | MD |   | MEDICAID | Y77147 | 01 | MA | BLUE CROSS BLUE SHIELD | OTHER |