1346389749 NPI number — MISSOURI DELTA FOOT AND ANKLE CENTERS, INC

Table of content: (NPI 1346389749)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346389749 NPI number — MISSOURI DELTA FOOT AND ANKLE CENTERS, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MISSOURI DELTA FOOT AND ANKLE CENTERS, INC
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:
FOOT AND ANKLE CENTERS OF SOUTHEAST MISSOURI
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:
1346389749
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/26/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
522 VIRGINIA ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SIKESTON
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63801-5812
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-472-2202
Provider Business Mailing Address Fax Number:
573-472-3720

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
522 VIRGINIA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SIKESTON
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63801-5812
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-472-2202
Provider Business Practice Location Address Fax Number:
573-472-3720
Provider Enumeration Date:
02/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PROTZEL
Authorized Official First Name:
HUGH
Authorized Official Middle Name:
RAYMOND
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
573-472-2202

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332B00000X , with the licence number: 000625 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 176040 . This is a "HEALTHLINK" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 507579407 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 55749 . This is a "GHP" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 626035208 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9890 . This is a "BLUE CROSS BLUE SHIELD MO" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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