Provider Demographics
NPI:1437278488
Name:PODIATRY ASSOCIATES, P.A., LOW COUNTRY FOOT & ANKLE INSTITUTE, INC.
Entity Type:Organization
Organization Name:PODIATRY ASSOCIATES, P.A., LOW COUNTRY FOOT & ANKLE INSTITUTE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:TRENTON
Authorized Official - Middle Name:K
Authorized Official - Last Name:STATLER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:843-524-0232
Mailing Address - Street 1:1084 RIBAUT RD
Mailing Address - Street 2:STE A
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29902-5494
Mailing Address - Country:US
Mailing Address - Phone:843-524-0232
Mailing Address - Fax:843-524-3323
Practice Address - Street 1:1084 RIBAUT RD
Practice Address - Street 2:STE A
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29902-5494
Practice Address - Country:US
Practice Address - Phone:843-524-0232
Practice Address - Fax:843-524-3323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC007222542213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPA4744Medicaid
0169920001OtherMEDICARE DME
0169920001OtherMEDICARE DME
=========OtherFED TAX ID