Provider Demographics
NPI:1962561480
Name:BRUNSWICK FOOT & ANKLE CENTER, LLC
Entity type:Organization
Organization Name:BRUNSWICK FOOT & ANKLE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:HILARY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:PELLETIER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:207-729-6686
Mailing Address - Street 1:2 UNION STREET
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011
Mailing Address - Country:US
Mailing Address - Phone:207-729-6686
Mailing Address - Fax:207-729-6687
Practice Address - Street 1:2 UNION STREET
Practice Address - Street 2:SUITE 1
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011
Practice Address - Country:US
Practice Address - Phone:207-729-6686
Practice Address - Fax:207-729-6687
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME133310000Medicaid
M186670OtherCIGNA
610202500OtherDEPT OF LABOR
MEDA6583Medicare PIN
MM8490Medicare PIN