Provider Demographics
NPI:1245431865
Name:SPEEDWAY PODIATRY INC.
Entity Type:Organization
Organization Name:SPEEDWAY PODIATRY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:A
Authorized Official - Last Name:GIBNEY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:317-241-2107
Mailing Address - Street 1:5388 W 10TH ST
Mailing Address - Street 2:
Mailing Address - City:SPEEDWAY
Mailing Address - State:IN
Mailing Address - Zip Code:46224-6818
Mailing Address - Country:US
Mailing Address - Phone:317-241-2107
Mailing Address - Fax:317-240-1198
Practice Address - Street 1:5388 W 10TH ST
Practice Address - Street 2:
Practice Address - City:SPEEDWAY
Practice Address - State:IN
Practice Address - Zip Code:46224-6818
Practice Address - Country:US
Practice Address - Phone:317-241-2107
Practice Address - Fax:317-240-1198
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-30
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN52000059A213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN087500Medicare ID - Type Unspecified