Provider Demographics
NPI:1154514032
Name:MIDWEST FOOTCARE, INC.
Entity type:Organization
Organization Name:MIDWEST FOOTCARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:LEWIS
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:VICHINSKY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:937-642-9936
Mailing Address - Street 1:245 STOCKSDALE DR
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43040-1563
Mailing Address - Country:US
Mailing Address - Phone:937-642-9936
Mailing Address - Fax:937-642-5537
Practice Address - Street 1:245 STOCKSDALE DR
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43040-1563
Practice Address - Country:US
Practice Address - Phone:937-642-9936
Practice Address - Fax:937-642-5537
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-23
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36-00-1774-V213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
102085AOtherALLIANCE BC
OH2457934Medicaid
000000066784OtherANTHEM BC
431803548OtherCHAMPUS
DB2142OtherRAILROAD MEDICARE
OH2457934Medicaid
=========001OtherMED MUTUAL
000000066784OtherANTHEM BC