1790714491 NPI number — ANKLE AND FOOT CENTERS OF MISSOURI P.C.

Table of content: (NPI 1790714491)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790714491 NPI number — ANKLE AND FOOT CENTERS OF MISSOURI P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANKLE AND FOOT CENTERS OF MISSOURI 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:
1790714491
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/29/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
407 NE 76TH TER
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GLADSTONE
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64118-1708
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
816-436-7900
Provider Business Mailing Address Fax Number:
816-436-0999

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
407 NE 76TH TER
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLADSTONE
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64118-1708
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-436-7900
Provider Business Practice Location Address Fax Number:
816-436-0999
Provider Enumeration Date:
07/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
THEOHARIDIS
Authorized Official First Name:
AKILIS
Authorized Official Middle Name:
MIKE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
816-436-7900

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  000747 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 291U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 505265009 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 365265016 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: CB6768 . This is a "RAILROAD AHN" identifier . This identifiers is of the category "OTHER".
  • Identifier: CB6767 . This is a "RAILROAD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 365265008 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 505265017 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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