Provider Demographics
NPI:1811087158
Name:HEALTHDRIVE PODIATRY GROUP, PC
Entity type:Organization
Organization Name:HEALTHDRIVE PODIATRY GROUP, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:TREASUER/PRACTICE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SHADI
Authorized Official - Middle Name:ADIB
Authorized Official - Last Name:ABBOUD
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:857-255-0486
Mailing Address - Street 1:100 CROSSING BLVD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:FRAMINGHAM
Mailing Address - State:MA
Mailing Address - Zip Code:01702-5555
Mailing Address - Country:US
Mailing Address - Phone:617-964-6681
Mailing Address - Fax:339-686-2561
Practice Address - Street 1:200 S EXECUTIVE DR
Practice Address - Street 2:SUITE 101
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-4216
Practice Address - Country:US
Practice Address - Phone:414-535-8134
Practice Address - Fax:414-535-8135
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HEALTHDRIVE PODIATRY GROUP, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-16
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41738600OtherDME
WI4864220004Medicare NSC