Provider Demographics
NPI:1043419625
Name:PODIATRY CLINIC, P.A.
Entity Type:Organization
Organization Name:PODIATRY CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:K
Authorized Official - Last Name:MCNEIL
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:316-685-3801
Mailing Address - Street 1:400 N WOODLAWN ST STE 211
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67208-4332
Mailing Address - Country:US
Mailing Address - Phone:316-685-3801
Mailing Address - Fax:316-685-6901
Practice Address - Street 1:400 N WOODLAWN ST STE 211
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67208-4332
Practice Address - Country:US
Practice Address - Phone:316-685-3801
Practice Address - Fax:316-685-6901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-13
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS12-00142213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS480029429OtherRRMEDICARE
KS100094390BMedicaid
KST43858Medicare UPIN
KS006770Medicare PIN
KS100094390BMedicaid