1679568919 NPI number — M & L PODIATRY PA

Table of content: (NPI 1679568919)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679568919 NPI number — M & L PODIATRY PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
M & L PODIATRY PA
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:
MATTHEWS FOOT CARE LINCOLN FOOT CARE WAXHAW FOOT CARE DR KEVIN L KILLI
Provider Other Organization Name Type Code:
3
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:
1679568919
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/06/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
534 W JOHN ST
Provider Second Line Business Mailing Address:
STE 100
Provider Business Mailing Address City Name:
MATTHEWS
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28105-5353
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-847-9788
Provider Business Mailing Address Fax Number:
704-849-2928

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
534 W JOHN ST
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
MATTHEWS
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28105-5353
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-847-9788
Provider Business Practice Location Address Fax Number:
704-849-2928
Provider Enumeration Date:
09/13/2005

Additional Information

Authorized Official

Authorized Official Last Name:
KILLIAN
Authorized Official First Name:
KEVIN
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PODIATRIST OWNER
Authorized Official Telephone Number:
704-847-9788

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  312 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 213E00000X , with the licence number: 367 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 890156X , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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