Provider Demographics
NPI:1538180674
Name:ASSOCIATED FOOT AND ANKLE SPECIALISTS OF OHIO INC
Entity type:Organization
Organization Name:ASSOCIATED FOOT AND ANKLE SPECIALISTS OF OHIO INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:NICELY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:937-293-8448
Mailing Address - Street 1:6200 PLEASANT AVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-4670
Mailing Address - Country:US
Mailing Address - Phone:937-435-6585
Mailing Address - Fax:937-435-6563
Practice Address - Street 1:1001 SHROYER RD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45419-3635
Practice Address - Country:US
Practice Address - Phone:937-293-8448
Practice Address - Fax:937-617-4840
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36003238213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2985739Medicaid
OH2922234Medicaid
OHDB9209OtherRAILROAD MEDICARE
OH9336471Medicare PIN
WVE089Medicare PIN
OHDB9209OtherRAILROAD MEDICARE