Provider Demographics
NPI:1174559579
Name:SEDALIA FOOT CLINIC PC
Entity type:Organization
Organization Name:SEDALIA FOOT CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:A
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-826-5897
Mailing Address - Street 1:519 E 13TH ST
Mailing Address - Street 2:
Mailing Address - City:SEDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65301-5909
Mailing Address - Country:US
Mailing Address - Phone:660-826-5897
Mailing Address - Fax:660-826-4691
Practice Address - Street 1:519 E 13TH ST
Practice Address - Street 2:
Practice Address - City:SEDALIA
Practice Address - State:MO
Practice Address - Zip Code:65301-5909
Practice Address - Country:US
Practice Address - Phone:660-826-5897
Practice Address - Fax:660-826-4691
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-25
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000587213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO366092807Medicaid
MO366092807Medicaid
L810000Medicare ID - Type Unspecified