Provider Demographics
NPI:1376642215
Name:WILLIAMSON FOOT CLINIC, PLLC
Entity Type:Organization
Organization Name:WILLIAMSON FOOT CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:BURTON
Authorized Official - Last Name:AVERY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:606-237-5000
Mailing Address - Street 1:28531 US HIGHWAY 119 STE 202
Mailing Address - Street 2:
Mailing Address - City:SOUTH WILLIAMSON
Mailing Address - State:KY
Mailing Address - Zip Code:41503-3928
Mailing Address - Country:US
Mailing Address - Phone:606-237-5000
Mailing Address - Fax:606-237-5001
Practice Address - Street 1:28531 US HIGHWAY 119 STE 202
Practice Address - Street 2:
Practice Address - City:SOUTH WILLIAMSON
Practice Address - State:KY
Practice Address - Zip Code:41503-3928
Practice Address - Country:US
Practice Address - Phone:606-237-5000
Practice Address - Fax:606-237-5001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY00295213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810004941Medicaid
KY80900301Medicaid
WV3810004941Medicaid
KY80900301Medicaid
WV9360051Medicare PIN