Provider Demographics
NPI:1154549640
Name:FOOT & ANKLE CLINICS OF SOUTHERN IOWA, PC
Entity type:Organization
Organization Name:FOOT & ANKLE CLINICS OF SOUTHERN IOWA, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:BYRON
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:641-684-8448
Mailing Address - Street 1:1005 PENNSYLVANIA AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:OTTUMWA
Mailing Address - State:IA
Mailing Address - Zip Code:52501-6413
Mailing Address - Country:US
Mailing Address - Phone:641-684-8448
Mailing Address - Fax:641-684-4055
Practice Address - Street 1:1005 PENNSYLVANIA AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:OTTUMWA
Practice Address - State:IA
Practice Address - Zip Code:52501-6413
Practice Address - Country:US
Practice Address - Phone:641-684-8448
Practice Address - Fax:641-684-4055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2015-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00453213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0249003Medicaid
IAT01418Medicare UPIN
IA1109550002Medicare NSC
IA0249003Medicaid