Provider Demographics
NPI:1174785679
Name:NORTH BAY PODIATRIC ASSOCIATES, P.A.
Entity type:Organization
Organization Name:NORTH BAY PODIATRIC ASSOCIATES, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:305-644-2212
Mailing Address - Street 1:5040 NW 7TH ST STE 635
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-3796
Mailing Address - Country:US
Mailing Address - Phone:305-644-2212
Mailing Address - Fax:786-475-7787
Practice Address - Street 1:5040 NW 7TH ST STE 635
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33126
Practice Address - Country:US
Practice Address - Phone:305-644-2212
Practice Address - Fax:786-475-7787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-26
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO3056213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004358400Medicaid
FL004358400Medicaid