1255435897 NPI number — MISSOURI FOOT AND ANKLE CLINICS, P.C.

Table of content: (NPI 1255435897)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255435897 NPI number — MISSOURI FOOT AND ANKLE CLINICS, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MISSOURI FOOT AND ANKLE CLINICS, 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:
Provider Other Organization Name Type Code:
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:
1255435897
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/25/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
256 SW WINTERPARK CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEES SUMMIT
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64081-4013
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
816-224-8660
Provider Business Mailing Address Fax Number:
816-200-9005

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1136 W 40 HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLUE SPRINGS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64015-4610
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-224-8660
Provider Business Practice Location Address Fax Number:
816-200-9005
Provider Enumeration Date:
09/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HANON
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
RAYMOND
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
816-224-8660

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  000774 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4349950001 . This is a "DMERC" identifier . This identifiers is of the category "OTHER".
  • Identifier: CJ9038 . This is a "RR MCR" identifier . This identifiers is of the category "OTHER".
  • Identifier: 506023506 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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