Provider Demographics
NPI:1699079665
Name:ADVANCED FOOT CARE CENTER, LLC
Entity type:Organization
Organization Name:ADVANCED FOOT CARE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMEBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:MEGARA
Authorized Official - Suffix:III
Authorized Official - Credentials:DPM
Authorized Official - Phone:856-579-8674
Mailing Address - Street 1:204 GROVE AVE
Mailing Address - Street 2:SUITE G
Mailing Address - City:THOROFARE
Mailing Address - State:NJ
Mailing Address - Zip Code:08086-2557
Mailing Address - Country:US
Mailing Address - Phone:856-579-8674
Mailing Address - Fax:856-579-8676
Practice Address - Street 1:204 GROVE AVE
Practice Address - Street 2:SUITE G
Practice Address - City:THOROFARE
Practice Address - State:NJ
Practice Address - Zip Code:08086-2557
Practice Address - Country:US
Practice Address - Phone:856-579-8674
Practice Address - Fax:856-579-8676
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-05
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00273100213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ240449OtherMEDICARE PTAN
NJU94599Medicare UPIN
NJ6704020001Medicare NSC