Provider Demographics
NPI:1528117553
Name:SOUTHSIDE FOOT CLINIC P C
Entity type:Organization
Organization Name:SOUTHSIDE FOOT CLINIC P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:J
Authorized Official - Middle Name:KARL
Authorized Official - Last Name:WINCKELBACH
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:317-882-9303
Mailing Address - Street 1:33 E COUNTY LINE RD STE B
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-1043
Mailing Address - Country:US
Mailing Address - Phone:317-882-9303
Mailing Address - Fax:317-882-6605
Practice Address - Street 1:33 E COUNTY LINE RD STE B
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-1043
Practice Address - Country:US
Practice Address - Phone:317-882-9303
Practice Address - Fax:317-882-6605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2008-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07000316213ES0103X, 213E00000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN265340Medicare PIN
IN4691620001Medicare NSC