Provider Demographics
NPI:1295807451
Name:AFFILIATED FOOT CARE CENTER, LLC
Entity type:Organization
Organization Name:AFFILIATED FOOT CARE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:E
Authorized Official - Last Name:FOSDICK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:860-349-8500
Mailing Address - Street 1:470 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLEFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06455-1210
Mailing Address - Country:US
Mailing Address - Phone:860-349-8500
Mailing Address - Fax:860-349-3081
Practice Address - Street 1:470 MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDDLEFIELD
Practice Address - State:CT
Practice Address - Zip Code:06455-1210
Practice Address - Country:US
Practice Address - Phone:860-349-8500
Practice Address - Fax:860-349-3081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000723213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004206951Medicaid
CTC03197Medicare PIN
CTU79658Medicare UPIN