Provider Demographics
NPI:1285947705
Name:ADVANCED FOOT & ANKLE CENTER, LLC
Entity type:Organization
Organization Name:ADVANCED FOOT & ANKLE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:STANLEY
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:208-785-6700
Mailing Address - Street 1:9 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-1702
Mailing Address - Country:US
Mailing Address - Phone:208-785-6700
Mailing Address - Fax:208-785-6767
Practice Address - Street 1:9 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-1702
Practice Address - Country:US
Practice Address - Phone:208-785-6700
Practice Address - Fax:208-785-6767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-26
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP156213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID480034721OtherMEDICARE RAILROAD
ID804309300Medicaid
IDP1571OtherBLUE CROSS
ID000010015672OtherBLUE SHIELD
ID341488OtherDMBA
ID461973001OtherDMERC
ID461973001OtherDMERC
ID804309300Medicaid
ID1285947705Medicare NSC