Provider Demographics
NPI:1669428991
Name:SUPPAN FOOT AND ANKLE CLINIC INC
Entity type:Organization
Organization Name:SUPPAN FOOT AND ANKLE CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:NORBERT
Authorized Official - Last Name:SUPPAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:330-642-6070
Mailing Address - Street 1:6200 PLEASANT AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-4671
Mailing Address - Country:US
Mailing Address - Phone:330-682-6070
Mailing Address - Fax:330-684-2822
Practice Address - Street 1:1710 PARADISE RD
Practice Address - Street 2:
Practice Address - City:ORRVILLE
Practice Address - State:OH
Practice Address - Zip Code:44667-9418
Practice Address - Country:US
Practice Address - Phone:330-682-6070
Practice Address - Fax:330-684-2822
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0512396Medicaid
OH1669428991OtherNPI
OH9272321Medicare ID - Type Unspecified
OH1669428991OtherNPI