1194909556 NPI number — PHYSICIANS FOOTCARE, LLC

Table of content: (NPI 1194909556)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194909556 NPI number — PHYSICIANS FOOTCARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHYSICIANS FOOTCARE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
THE FOOT INSTITUTE, LLC
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194909556
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/23/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1730 ST JULIAN PLACE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBIA
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29204-2044
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-256-6776
Provider Business Mailing Address Fax Number:
803-256-6778

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1730 SAINT JULIAN PL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29204
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-256-6776
Provider Business Practice Location Address Fax Number:
803-256-6778
Provider Enumeration Date:
12/20/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
RAY
Authorized Official First Name:
KEVIN
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
803-256-6776

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: DN1264 . This is a "MEDICARE RR" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: GP9909 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".