Provider Demographics
NPI:1811063274
Name:FAMILY FOOT AND ANKLE CENTER, SC
Entity type:Organization
Organization Name:FAMILY FOOT AND ANKLE CENTER, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DIRK
Authorized Official - Middle Name:SAUL
Authorized Official - Last Name:HALVERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:920-733-5345
Mailing Address - Street 1:436 E LONGVIEW DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-2166
Mailing Address - Country:US
Mailing Address - Phone:920-733-5345
Mailing Address - Fax:920-733-1390
Practice Address - Street 1:436 E LONGVIEW DR
Practice Address - Street 2:SUITE A
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-2166
Practice Address - Country:US
Practice Address - Phone:920-733-5345
Practice Address - Fax:920-733-1390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2008-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI877213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
5673670001Medicare NSC