Provider Demographics
NPI:1730441254
Name:KSU FOOT & ANKLE CLINIC
Entity type:Organization
Organization Name:KSU FOOT & ANKLE CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:DIBACCO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:814-474-7499
Mailing Address - Street 1:7000 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44103-4014
Mailing Address - Country:US
Mailing Address - Phone:216-231-5612
Mailing Address - Fax:
Practice Address - Street 1:7000 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44103-4014
Practice Address - Country:US
Practice Address - Phone:216-231-5612
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-11
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
6703950001Medicare NSC