1205911906 NPI number — SMOKY MOUNTAIN FOOT CLINIC PA

Table of content: (NPI 1205911906)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205911906 NPI number — SMOKY MOUNTAIN FOOT CLINIC PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SMOKY MOUNTAIN FOOT CLINIC PA
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:
1205911906
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/09/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 278
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLYDE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28721-0278
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
828-452-4343
Provider Business Mailing Address Fax Number:
828-452-1477

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
573 MERRIMON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ASHEVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28804-3490
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
828-254-7716
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BANKS
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
D
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
828-452-4343

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  346 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213E00000X , with the licence number: B01 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213E00000X , with the licence number: 380 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213E00000X , with the licence number: 469 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0808P . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 89086B , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0807K . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 5911409 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 890801K , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 890808P , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0800A . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 0806B . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 890800A , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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