Provider Demographics
NPI:1174595409
Name:CENTER FOR ADVANCED FOOT & ANKLE SURGERY INC
Entity type:Organization
Organization Name:CENTER FOR ADVANCED FOOT & ANKLE SURGERY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DELEGATED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLTZMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:314-991-3668
Mailing Address - Street 1:PO BOX 14000
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4033
Mailing Address - Country:US
Mailing Address - Phone:314-991-3668
Mailing Address - Fax:314-991-3665
Practice Address - Street 1:621 S NEW BALLAS RD
Practice Address - Street 2:SUITE 7005B
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8232
Practice Address - Country:US
Practice Address - Phone:314-991-3668
Practice Address - Fax:314-991-3665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-02
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000821213ES0103X
MO2000157310213ES0103X
MO000765213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000014684Medicare PIN
MO5558370002Medicare NSC