Provider Demographics
NPI:1457432130
Name:FOOT DOCTOR OF RAPPAHANNOCK LTD
Entity type:Organization
Organization Name:FOOT DOCTOR OF RAPPAHANNOCK LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ILENE
Authorized Official - Middle Name:S
Authorized Official - Last Name:TERRELL
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:540-548-3668
Mailing Address - Street 1:12010 KILARNEY DR
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBRG
Mailing Address - State:VA
Mailing Address - Zip Code:22407-7207
Mailing Address - Country:US
Mailing Address - Phone:540-548-3668
Mailing Address - Fax:540-548-0019
Practice Address - Street 1:12010 KILARNEY DR
Practice Address - Street 2:
Practice Address - City:FREDERICKSBRG
Practice Address - State:VA
Practice Address - Zip Code:22407-7207
Practice Address - Country:US
Practice Address - Phone:540-548-3668
Practice Address - Fax:540-548-0019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103000702213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA009302417Medicaid
VA6068210001Medicare NSC
VA0380690003Medicare NSC
VA009302417Medicaid
VAT21410Medicare UPIN