Provider Demographics
NPI:1154430411
Name:ADVANCED PODIATRY PA
Entity type:Organization
Organization Name:ADVANCED PODIATRY PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:A
Authorized Official - Last Name:DAVISON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:908-688-5577
Mailing Address - Street 1:1308 MORRIS AVENUE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:UNION
Mailing Address - State:NJ
Mailing Address - Zip Code:07083-3331
Mailing Address - Country:US
Mailing Address - Phone:908-688-5577
Mailing Address - Fax:908-688-2755
Practice Address - Street 1:1308 MORRIS AVENUE
Practice Address - Street 2:SUITE 104
Practice Address - City:UNION
Practice Address - State:NJ
Practice Address - Zip Code:07083-3331
Practice Address - Country:US
Practice Address - Phone:908-688-5577
Practice Address - Fax:908-688-2755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00196300213E00000X
NJ25MD00257000213E00000X
NYN0046131213E00000X
NYN006069213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
985507OtherAMERIHEALTH
0859237000OtherAMERIHEALTH
NJ1138221OtherHORIZON HEALTH
NJ8261903Medicaid
NJ3964640001Medicare NSC
U02004Medicare UPIN
CH5852Medicare ID - Type UnspecifiedRAIL ROAD
NJ1138221OtherHORIZON HEALTH
U80197Medicare UPIN