1780780023 NPI number — MIDWEST FOOT AND ANKLE, LLC

Table of content: (NPI 1780780023)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780780023 NPI number — MIDWEST FOOT AND ANKLE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIDWEST FOOT AND ANKLE, 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:
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:
1780780023
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/08/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3850 SHORE DR
Provider Second Line Business Mailing Address:
SUITE 301
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46254-5621
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-297-3338
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3850 SHORE DR
Provider Second Line Business Practice Location Address:
SUITE 301
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46254-5621
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-297-3338
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HOLSTON
Authorized Official First Name:
KIRK
Authorized Official Middle Name:
S
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
317-297-3338

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  070000768A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000364508 . This is a "ANTHEM BCBS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 0005497063 . This is a "AETNA" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200527610B , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200527610A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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