Provider Demographics
NPI:1861511875
Name:CREEK CROSSING PODIATRY LLC
Entity type:Organization
Organization Name:CREEK CROSSING PODIATRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:BERNADETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:GIANGRECO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:609-261-9660
Mailing Address - Street 1:309 CREEK CROSSING BLVD
Mailing Address - Street 2:SUITE 309
Mailing Address - City:HAINESPORT
Mailing Address - State:NJ
Mailing Address - Zip Code:08036-2767
Mailing Address - Country:US
Mailing Address - Phone:609-261-9660
Mailing Address - Fax:609-261-9440
Practice Address - Street 1:309 CREEK CROSSING BLVD
Practice Address - Street 2:SUITE 309
Practice Address - City:HAINESPORT
Practice Address - State:NJ
Practice Address - Zip Code:08036-2767
Practice Address - Country:US
Practice Address - Phone:609-261-9660
Practice Address - Fax:609-261-9440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00273500213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5971990001Medicare NSC
NJ080007Medicare ID - Type Unspecified