Provider Demographics
NPI:1245424688
Name:LA-MISS PODIATRY & FOOT CLINIC
Entity Type:Organization
Organization Name:LA-MISS PODIATRY & FOOT CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:F
Authorized Official - Last Name:PHELAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:601-790-7710
Mailing Address - Street 1:2429 W COMMERCE ST STE A
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-3124
Mailing Address - Country:US
Mailing Address - Phone:228-875-1141
Mailing Address - Fax:228-875-6885
Practice Address - Street 1:2429 W COMMERCE ST STE A
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-3124
Practice Address - Country:US
Practice Address - Phone:228-875-1141
Practice Address - Fax:228-875-6885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-29
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS80145213EP1101X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08400304Medicaid
MS05884801Medicaid
MS4758560001Medicare NSC