Provider Demographics
NPI:1295133627
Name:COMPLETE FOOT AND ANKLE CARE
Entity type:Organization
Organization Name:COMPLETE FOOT AND ANKLE CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:DEANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:PETRAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-737-7016
Mailing Address - Street 1:1512 COMMERCE ST
Mailing Address - Street 2:
Mailing Address - City:WELLSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26070-1323
Mailing Address - Country:US
Mailing Address - Phone:740-282-0861
Mailing Address - Fax:304-737-2964
Practice Address - Street 1:1512 COMMERCE ST
Practice Address - Street 2:
Practice Address - City:WELLSBURG
Practice Address - State:WV
Practice Address - Zip Code:26070-1323
Practice Address - Country:US
Practice Address - Phone:304-737-2964
Practice Address - Fax:304-737-4822
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-17
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV00376213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1285657460OtherINDIVIDUAL NPI
WV3810019307Medicaid
WV4095902Medicare PIN