Provider Demographics
NPI:1114002813
Name:SMOKY MOUNTAIN FOOT CLINIC PA
Entity Type:Organization
Organization Name:SMOKY MOUNTAIN FOOT CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:D
Authorized Official - Last Name:BANKS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:828-452-4343
Mailing Address - Street 1:PO BOX 278
Mailing Address - Street 2:
Mailing Address - City:CLYDE
Mailing Address - State:NC
Mailing Address - Zip Code:28721-0278
Mailing Address - Country:US
Mailing Address - Phone:828-452-4343
Mailing Address - Fax:828-452-1477
Practice Address - Street 1:32 ASHEVILLE HIGHWAY
Practice Address - Street 2:
Practice Address - City:SYLVA
Practice Address - State:NC
Practice Address - Zip Code:28779-2708
Practice Address - Country:US
Practice Address - Phone:828-586-8950
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2015-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC301213E00000X, 213ES0131X
NC346213E00000X, 213ES0131X
NC469213E00000X, 213ES0103X
NC563213E00000X, 213ES0131X
NC547213E00000X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0806BOtherBCBS
NC0808POtherBCBS
NC5911411Medicaid
NC08081KOtherBCBS
NC0800AOtherBCBS
NC890801KMedicaid
U44307Medicare UPIN
NC0571680004Medicare NSC
NC2432623FMedicare PIN
U91975Medicare UPIN
2433653Medicare ID - Type Unspecified
2433053CMedicare ID - Type Unspecified
NC0808POtherBCBS
2432485BMedicare ID - Type Unspecified
NC0806BOtherBCBS
U13002Medicare UPIN