Provider Demographics
NPI:1275701294
Name:ADVANCED FOOT CLINIC PLLC
Entity Type:Organization
Organization Name:ADVANCED FOOT CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:FARZAD
Authorized Official - Middle Name:
Authorized Official - Last Name:FARYABI
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:601-936-3445
Mailing Address - Street 1:2475 LAKELAND DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-9505
Mailing Address - Country:US
Mailing Address - Phone:601-936-3445
Mailing Address - Fax:601-936-7434
Practice Address - Street 1:2475 LAKELAND DR
Practice Address - Street 2:SUITE B
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9505
Practice Address - Country:US
Practice Address - Phone:601-936-3445
Practice Address - Fax:601-936-7434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-12
Last Update Date:2013-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS80147213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS427495756OtherBLUE CROSS BLUE SHIELD
MS00120443Medicaid
MS4354890001Medicare NSC
MS480000106Medicare PIN
MS427495756OtherBLUE CROSS BLUE SHIELD