Provider Demographics
NPI:1972532125
Name:CLAY COUNTY PODIATRY, LLC
Entity type:Organization
Organization Name:CLAY COUNTY PODIATRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:MIRANDA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:GOODALE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:812-448-9290
Mailing Address - Street 1:955 W CRAIG AVE
Mailing Address - Street 2:
Mailing Address - City:BRAZIL
Mailing Address - State:IN
Mailing Address - Zip Code:47834-7400
Mailing Address - Country:US
Mailing Address - Phone:812-448-9290
Mailing Address - Fax:812-448-9296
Practice Address - Street 1:955 W CRAIG AVE
Practice Address - Street 2:
Practice Address - City:BRAZIL
Practice Address - State:IN
Practice Address - Zip Code:47834-7400
Practice Address - Country:US
Practice Address - Phone:812-448-9290
Practice Address - Fax:812-448-9296
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2019-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07001015A213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000392910OtherBLUECROSSBLUESHIELD
IN0385202OtherCIGNA
IN200825350AMedicaid
=========OtherUNITED HEALTHCARE
=========OtherUMWA
IN0385202OtherCIGNA
V10649Medicare UPIN
239670AMedicare PIN
=========OtherTRICARE NORTH