Provider Demographics
NPI:1891712451
Name:WHITE BEAR FOOT CLINIC INC
Entity type:Organization
Organization Name:WHITE BEAR FOOT CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:N
Authorized Official - Last Name:WOROBEL
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:651-426-3995
Mailing Address - Street 1:4653 WHITE BEAR PKWY
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-3300
Mailing Address - Country:US
Mailing Address - Phone:651-426-3995
Mailing Address - Fax:651-426-5626
Practice Address - Street 1:4653 WHITE BEAR PKWY
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-3300
Practice Address - Country:US
Practice Address - Phone:651-426-3995
Practice Address - Fax:651-426-5626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN121124OtherHEALTH PARTNERS
MNJ890OtherUCARE MN PAYEE ID
MN077R8WHOtherBCBS MN
WI43240000Medicaid
WIDG2091Medicare PIN
MNJ890OtherUCARE MN PAYEE ID
WI43240000Medicaid
MNDF3527Medicare PIN