Provider Demographics
NPI:1992775787
Name:MONROE FOOT CLINIC SC
Entity type:Organization
Organization Name:MONROE FOOT CLINIC SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:F
Authorized Official - Last Name:KIND
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:608-325-9175
Mailing Address - Street 1:1500 11TH ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:WI
Mailing Address - Zip Code:53566
Mailing Address - Country:US
Mailing Address - Phone:608-325-9175
Mailing Address - Fax:608-325-9176
Practice Address - Street 1:1500 11TH ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WI
Practice Address - Zip Code:53566
Practice Address - Country:US
Practice Address - Phone:608-325-9175
Practice Address - Fax:608-325-9176
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-24
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI712025213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43264500Medicaid
480025121OtherRETIRED RAILROAD MED
WI549725OtherDEAN CARE
=========012OtherWISCONSIN BLUE SHIEL
480025121OtherRETIRED RAILROAD MED
WI43264500Medicaid
=========012OtherWISCONSIN BLUE SHIEL
WI4783590001Medicare NSC
WI000089687Medicare PIN