Provider Demographics
NPI:1588697650
Name:REYNOLDSBURG PODIATRY CENTER LLC
Entity type:Organization
Organization Name:REYNOLDSBURG PODIATRY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN - MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:BROCK
Authorized Official - Middle Name:A
Authorized Official - Last Name:LIDEN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:614-866-3182
Mailing Address - Street 1:7509 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-7268
Mailing Address - Country:US
Mailing Address - Phone:614-866-3182
Mailing Address - Fax:614-866-5627
Practice Address - Street 1:7509 E MAIN ST
Practice Address - Street 2:
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068-7268
Practice Address - Country:US
Practice Address - Phone:614-866-3182
Practice Address - Fax:614-866-5627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE3472OtherNEW RR MEDICARE GROUP
OH2619161Medicaid
OH5616730001OtherNEW DMERC GROUP
OHRE9358991Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER