Provider Demographics
NPI:1093873838
Name:MIDWEST FOOT & ANKLE SPECIALISTS, LLC
Entity Type:Organization
Organization Name:MIDWEST FOOT & ANKLE SPECIALISTS, LLC
Other - Org Name:BURNSVILLE FOOT CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:952-890-4061
Mailing Address - Street 1:12940 HARRIET AVE S STE 210
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-2680
Mailing Address - Country:US
Mailing Address - Phone:952-890-4061
Mailing Address - Fax:
Practice Address - Street 1:12940 HARRIET AVE S STE 210
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-2680
Practice Address - Country:US
Practice Address - Phone:952-890-4061
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN0708630008Medicare PIN
MNC02520Medicare PIN
MN0708630008Medicare NSC