Provider Demographics
NPI:1275702086
Name:FOOT GROUP INC
Entity Type:Organization
Organization Name:FOOT GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:865-966-5775
Mailing Address - Street 1:PO BOX 22429
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37933-0429
Mailing Address - Country:US
Mailing Address - Phone:865-966-5775
Mailing Address - Fax:865-966-5743
Practice Address - Street 1:10918 KINGSTON PIKE
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37934-2931
Practice Address - Country:US
Practice Address - Phone:865-966-5775
Practice Address - Fax:865-966-5743
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-26
Last Update Date:2015-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDPM170213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN2008661OtherBLUE SHIELD
TN3350711Medicaid
TN3350711Medicaid