Provider Demographics
NPI:1063630291
Name:AMBULATORY FOOT CENTER PC
Entity type:Organization
Organization Name:AMBULATORY FOOT CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXCUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:L
Authorized Official - Last Name:SIMCHUK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:541-471-7056
Mailing Address - Street 1:1619 NW HAWTHORNE AVE
Mailing Address - Street 2:STE 110
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-6008
Mailing Address - Country:US
Mailing Address - Phone:541-471-7056
Mailing Address - Fax:
Practice Address - Street 1:1619 NW HAWTHORNE AVE STE 110
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-6008
Practice Address - Country:US
Practice Address - Phone:541-471-7056
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2009-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP00291213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORU62663Medicare UPIN
OR5004530001Medicare NSC
ORU69580Medicare UPIN