1982667366 NPI number — MID-MISSOURI FOOT AND ANKLE CENTER

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 1982667366 NPI number — MID-MISSOURI FOOT AND ANKLE CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MID-MISSOURI FOOT AND ANKLE CENTER
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:
ANDERSON FOOT 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:
1982667366
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/12/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 130
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROLLA
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65402-0130
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-341-2971
Provider Business Mailing Address Fax Number:
573-341-8174

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1210 HOMELIFE PLZ
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROLLA
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65401-2512
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-341-2971
Provider Business Practice Location Address Fax Number:
573-341-8174
Provider Enumeration Date:
04/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WATSON
Authorized Official First Name:
KARA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
573-341-2971

Provider Taxonomy Codes

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

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





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