Provider Demographics
NPI:1346389749
Name:MISSOURI DELTA FOOT AND ANKLE CENTERS, INC
Entity type:Organization
Organization Name:MISSOURI DELTA FOOT AND ANKLE CENTERS, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HUGH
Authorized Official - Middle Name:RAYMOND
Authorized Official - Last Name:PROTZEL
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:573-472-2202
Mailing Address - Street 1:522 VIRGINIA ST
Mailing Address - Street 2:
Mailing Address - City:SIKESTON
Mailing Address - State:MO
Mailing Address - Zip Code:63801-5812
Mailing Address - Country:US
Mailing Address - Phone:573-472-2202
Mailing Address - Fax:573-472-3720
Practice Address - Street 1:522 VIRGINIA ST
Practice Address - Street 2:
Practice Address - City:SIKESTON
Practice Address - State:MO
Practice Address - Zip Code:63801-5812
Practice Address - Country:US
Practice Address - Phone:573-472-2202
Practice Address - Fax:573-472-3720
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
213E00000X
MO000625332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO176040OtherHEALTHLINK
MO507579407Medicaid
MO55749OtherGHP
MO626035208Medicaid
MO9890OtherBLUE CROSS BLUE SHIELD MO
MO0557920001Medicare NSC
MO990001612Medicare PIN
MO507579407Medicaid