Provider Demographics
NPI:1417113176
Name:REGIONAL FOOT AND ANKLE, LLC
Entity type:Organization
Organization Name:REGIONAL FOOT AND ANKLE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATT
Authorized Official - Middle Name:CLAYTON
Authorized Official - Last Name:GARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:417-326-6200
Mailing Address - Street 1:785 E DRAKE ST
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:MO
Mailing Address - Zip Code:65613-2739
Mailing Address - Country:US
Mailing Address - Phone:417-326-6200
Mailing Address - Fax:417-777-7463
Practice Address - Street 1:785 E DRAKE ST
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613-2739
Practice Address - Country:US
Practice Address - Phone:417-326-6200
Practice Address - Fax:417-777-7463
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-01
Last Update Date:2009-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005017337213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO307420505Medicaid
MO307420505Medicaid
MO6213320001Medicare NSC