1720173149 NPI number — WEST SYCAMORE PODIATRY, INC

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 1720173149 NPI number — WEST SYCAMORE PODIATRY, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WEST SYCAMORE PODIATRY, 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:
ADVANCED FOOT & ANKLE CLINIC
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:
1720173149
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/03/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3611 S REED RD
Provider Second Line Business Mailing Address:
SUITE 104
Provider Business Mailing Address City Name:
KOKOMO
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46902-3828
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
765-453-5892
Provider Business Mailing Address Fax Number:
765-453-8262

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3611 S REED RD
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
KOKOMO
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46902-3828
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-453-5892
Provider Business Practice Location Address Fax Number:
765-453-8262
Provider Enumeration Date:
10/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LEWIS
Authorized Official First Name:
STEPHANIE
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
765-453-5892

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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