Provider Demographics
NPI:1538237474
Name:ADVANCED FOOT & ANKLE CENTER, PC
Entity type:Organization
Organization Name:ADVANCED FOOT & ANKLE CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:E
Authorized Official - Last Name:BLOOM
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:704-662-8336
Mailing Address - Street 1:137 PROFESSIONAL PARK DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-6540
Mailing Address - Country:US
Mailing Address - Phone:704-662-8336
Mailing Address - Fax:704-662-8525
Practice Address - Street 1:137 PROFESSIONAL PARK DR.
Practice Address - Street 2:SUITE C
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117
Practice Address - Country:US
Practice Address - Phone:704-662-8336
Practice Address - Fax:704-662-8525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC001752814213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5905761Medicaid
NC2344687Medicare PIN
NC5819850001Medicare NSC