1154549640 NPI number — FOOT & ANKLE CLINICS OF SOUTHERN IOWA, PC

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 1154549640 NPI number — FOOT & ANKLE CLINICS OF SOUTHERN IOWA, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOOT & ANKLE CLINICS OF SOUTHERN IOWA, PC
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:
6
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:
1154549640
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/17/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1005 PENNSYLVANIA AVE
Provider Second Line Business Mailing Address:
SUITE 202
Provider Business Mailing Address City Name:
OTTUMWA
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52501-6413
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
641-684-8448
Provider Business Mailing Address Fax Number:
641-684-4055

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1005 PENNSYLVANIA AVE
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
OTTUMWA
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52501-6413
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
641-684-8448
Provider Business Practice Location Address Fax Number:
641-684-4055
Provider Enumeration Date:
04/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KING
Authorized Official First Name:
SCOTT
Authorized Official Middle Name:
BYRON
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
641-684-8448

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  00453 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0249003 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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