1093019713 NPI number — FIRST STEP FOOT AND ANKLE

Table of content: (NPI 1093019713)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093019713 NPI number — FIRST STEP FOOT AND ANKLE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FIRST STEP FOOT AND ANKLE
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:
1093019713
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/10/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11568 PINE FOREST DR
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:
65401-5427
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-578-0939
Provider Business Mailing Address Fax Number:
573-426-6051

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
806 HWY 72 E
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-578-0939
Provider Business Practice Location Address Fax Number:
573-426-6051
Provider Enumeration Date:
01/10/2011

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
CHRISTOPHER
Authorized Official Middle Name:
L
Authorized Official Title or Position:
DOCTOR OF PODIATRIC MEDICINE
Authorized Official Telephone Number:
573-578-0939

Provider Taxonomy Codes

  • Taxonomy code: 261QP1100X , with the licence number:  000803 , 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)

  • Identifier: 1154337202 . This is a "NPI" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 305351900 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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