Provider Demographics
NPI:1174739940
Name:NORTHEAST FAMILY FOOT CARE, PC
Entity type:Organization
Organization Name:NORTHEAST FAMILY FOOT CARE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:G
Authorized Official - Last Name:MYERS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:215-673-3200
Mailing Address - Street 1:9892 BUSTLETON AVE
Mailing Address - Street 2:SUITE 303
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19115-2184
Mailing Address - Country:US
Mailing Address - Phone:215-673-3200
Mailing Address - Fax:215-673-3884
Practice Address - Street 1:9892 BUSTLETON AVE
Practice Address - Street 2:SUITE 303
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19115-2184
Practice Address - Country:US
Practice Address - Phone:215-673-3200
Practice Address - Fax:215-673-3884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2009-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC004123-L213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAGOO1124200OtherAMERICHOICE
PA32994OtherHEALTH ANDSENIOR PARTNERS
PA480034747OtherRAILROAD MEDICARE
PA2018883000OtherINDEPENDENCE BLUE CROSS
PAGOO1124200OtherAMERICHOICE