Provider Demographics
NPI:1124350087
Name:EXCELSIOR PODIATRY CLINIC PLLC
Entity type:Organization
Organization Name:EXCELSIOR PODIATRY CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO, PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ELIJAH
Authorized Official - Last Name:BELL
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:901-516-4005
Mailing Address - Street 1:PO BOX 460
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:TN
Mailing Address - Zip Code:38060-0460
Mailing Address - Country:US
Mailing Address - Phone:901-516-4005
Mailing Address - Fax:901-516-4023
Practice Address - Street 1:214 LAKEVIEW RD
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:TN
Practice Address - Zip Code:38068-9737
Practice Address - Country:US
Practice Address - Phone:901-516-4005
Practice Address - Fax:901-516-4023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-03
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDPM0000000649302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN33542121Medicare PIN