1558857250 NPI number — FOOT & ANKLE CONSULTANTS OF TEXAS, LLC

Table of content: (NPI 1558857250)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558857250 NPI number — FOOT & ANKLE CONSULTANTS OF TEXAS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOOT & ANKLE CONSULTANTS OF TEXAS, LLC
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:
1558857250
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/12/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
412 VILLAGE DR STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MURPHY
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75094-4634
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-427-3228
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
412 VILLAGE DR STE 300
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MURPHY
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75094-4634
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-881-0110
Provider Business Practice Location Address Fax Number:
972-633-3721
Provider Enumeration Date:
07/05/2018

Additional Information

Authorized Official

Authorized Official Last Name:
BAXTER
Authorized Official First Name:
MARCUS
Authorized Official Middle Name:
ALLEN
Authorized Official Title or Position:
OWNER/ PODIATRIC SURGEON
Authorized Official Telephone Number:
972-881-0110

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  2344 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QP1100X , with the licence number: 2344 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 2344 . This is a "TEXAS PODIATRY LICENSE FROM TDLR" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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