Provider Demographics
NPI:1366591596
Name:EASY STRIDE PAIN & INJURY CENTER, PC
Entity type:Organization
Organization Name:EASY STRIDE PAIN & INJURY CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:J
Authorized Official - Middle Name:GREGORY
Authorized Official - Last Name:BANCROFT
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:215-222-2225
Mailing Address - Street 1:4014 LANCASTER AVE # A
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-1712
Mailing Address - Country:US
Mailing Address - Phone:215-222-2225
Mailing Address - Fax:215-222-3070
Practice Address - Street 1:4014 LANCASTER AVE # A
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-1712
Practice Address - Country:US
Practice Address - Phone:215-222-2225
Practice Address - Fax:215-222-3070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC-001795-L213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1073543559OtherNPI INDIVIDUAL
PA0500527Medicaid
PA1049959OtherKEYSTONE MERCY - EASY STR
PA31700OtherKEYSTONE MERCY INDIVIDUAL
PA0050052704OtherAMERICHOICE OF PA INDIVID
PA1049959OtherKEYSTONE MERCY - EASY STR
PABA066714Medicare ID - Type Unspecified