Provider Demographics
NPI:1063515526
Name:FAMILY FOOT CLINIC, SC
Entity type:Organization
Organization Name:FAMILY FOOT CLINIC, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:IAN
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:FURNESS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:920-921-1669
Mailing Address - Street 1:21 S MARR ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-4334
Mailing Address - Country:US
Mailing Address - Phone:920-921-1669
Mailing Address - Fax:920-921-7950
Practice Address - Street 1:21 S MARR ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-4334
Practice Address - Country:US
Practice Address - Phone:920-921-1669
Practice Address - Fax:920-921-7950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2010-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WICQ2458OtherRR/MEDICARE
WI43264100Medicaid
WI=========016OtherANTHEM BLUE CROSSBLUE SHI
WI=========016OtherANTHEM BLUE CROSSBLUE SHI
WICQ2458OtherRR/MEDICARE
000085810Medicare PIN