Provider Demographics
NPI:1386807543
Name:FOOTSOURCE MD, LLC
Entity type:Organization
Organization Name:FOOTSOURCE MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:H
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:614-895-8747
Mailing Address - Street 1:300 POLARIS PKWY
Mailing Address - Street 2:SUITE 2000
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43082-7989
Mailing Address - Country:US
Mailing Address - Phone:614-895-8747
Mailing Address - Fax:614-882-6503
Practice Address - Street 1:300 POLARIS PKWY
Practice Address - Street 2:SUITE 2000
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43082-7989
Practice Address - Country:US
Practice Address - Phone:614-895-8747
Practice Address - Fax:614-882-6503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-08
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH25-901188332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment