1154571495 NPI number — MID-SOUTH FOOT & ANKLE CLINIC P C

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154571495 NPI number — MID-SOUTH FOOT & ANKLE CLINIC P C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MID-SOUTH FOOT & ANKLE CLINIC P C
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:
MID-SOUTH FOOT CARE CENTER
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:
1154571495
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/29/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1118
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORREST CITY
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72336-1118
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-732-3131
Provider Business Mailing Address Fax Number:
870-732-1301

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
302 S RHODES ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST MEMPHIS
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72301-4215
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-732-3131
Provider Business Practice Location Address Fax Number:
870-732-1301
Provider Enumeration Date:
09/23/2008

Additional Information

Authorized Official

Authorized Official Last Name:
KHUMALO
Authorized Official First Name:
BHEKUMUZI
Authorized Official Middle Name:
M
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
870-732-3131

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  177 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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