Provider Demographics
NPI:1861692402
Name:MOBILE PODIATRIST, PC
Entity type:Organization
Organization Name:MOBILE PODIATRIST, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:IRENE
Authorized Official - Middle Name:ERICA
Authorized Official - Last Name:ROGE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:317-697-6536
Mailing Address - Street 1:1558 VICTORIA CT
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-7884
Mailing Address - Country:US
Mailing Address - Phone:317-697-6536
Mailing Address - Fax:
Practice Address - Street 1:1558 VICTORIA CT
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-7884
Practice Address - Country:US
Practice Address - Phone:317-697-6536
Practice Address - Fax:317-859-2923
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-23
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016-004848213EP1101X
IN07001009A213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INDF0688OtherRAILROAD MEDICARE
ILDE1825OtherRAILROAD MEDICARE
INDF0688OtherRAILROAD MEDICARE
IN6505710001Medicare NSC
IN233170Medicare PIN