Provider Demographics
NPI:1093876757
Name:FISHER FOOT CLINIC, LLC
Entity Type:Organization
Organization Name:FISHER FOOT CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANA
Authorized Official - Middle Name:J
Authorized Official - Last Name:FISHER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:803-536-2100
Mailing Address - Street 1:135 EXPRESS LN
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29118-2475
Mailing Address - Country:US
Mailing Address - Phone:803-536-2100
Mailing Address - Fax:803-536-4399
Practice Address - Street 1:135 EXPRESS LN
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29118-2475
Practice Address - Country:US
Practice Address - Phone:803-536-2100
Practice Address - Fax:803-536-4399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC00567213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP9922Medicaid
SC5405470001Medicare NSC
SCGP9922Medicaid
SCU96190Medicare UPIN