Basic Information
| Provider Information | |||||||||
| NPI: | 1710995733 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PREMIER FOOT AND ANKLE SPECIALISTS PA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PREMIER FOOT AND ANKLE SPECIALISTS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4120 WOODMERE PARK BLVD STE 5 | ||||||||
| Address2: | |||||||||
| City: | VENICE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342935373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9414880222 | ||||||||
| FaxNumber: | 9414801668 | ||||||||
| Practice Location | |||||||||
| Address1: | 4120 WOODMERE PARK BLVD STE 5 | ||||||||
| Address2: | |||||||||
| City: | VENICE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342935373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9414880222 | ||||||||
| FaxNumber: | 9414801668 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2006 | ||||||||
| LastUpdateDate: | 04/05/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BAYLINSON | ||||||||
| AuthorizedOfficialFirstName: | NICOLE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CONSULTANT | ||||||||
| AuthorizedOfficialTelephone: | 8568736065 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213EP1101X | PO-1580 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Primary Podiatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 041248100 | 05 | FL | MEDICAID | 74640 | 01 | FL | GROUP BCBS | OTHER |