Provider Demographics
NPI:1194725002
Name:FOOT & ANKLE GROUP OF SOUTHWEST FLORIDA, PA
Entity type:Organization
Organization Name:FOOT & ANKLE GROUP OF SOUTHWEST FLORIDA, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JEROLD
Authorized Official - Middle Name:S
Authorized Official - Last Name:GOLDSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-936-5400
Mailing Address - Street 1:5238 MASON CORBIN CT
Mailing Address - Street 2:SUITE 102
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-7738
Mailing Address - Country:US
Mailing Address - Phone:239-936-5400
Mailing Address - Fax:239-936-9572
Practice Address - Street 1:5238 MASON CORBIN CT
Practice Address - Street 2:SUITE 102
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-7738
Practice Address - Country:US
Practice Address - Phone:239-936-5400
Practice Address - Fax:239-936-9572
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-21
Last Update Date:2017-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
213E00000X, 261QP1100X
FLPO-1326213ES0103X
FLPO-2020213ES0103X
FLPO-1693213ES0103X
FLPO-3613213ES0103X
FLPO-3722213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatricGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL340184700Medicaid
FLCN1511OtherRAILROAD MEDICARE
FL39243Medicare ID - Type Unspecified
FL340184700Medicaid