Provider Demographics
NPI:1437297595
Name:OLIVER FOOT CLINIC, INC.
Entity Type:Organization
Organization Name:OLIVER FOOT CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:WADE
Authorized Official - Last Name:OLIVER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:931-684-8884
Mailing Address - Street 1:P.O. BOX 766
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37162-0766
Mailing Address - Country:US
Mailing Address - Phone:931-684-8884
Mailing Address - Fax:931-684-8808
Practice Address - Street 1:635 N. MAIN STREET
Practice Address - Street 2:SUITE A
Practice Address - City:SHELBYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37160-3235
Practice Address - Country:US
Practice Address - Phone:931-684-8884
Practice Address - Fax:931-684-8808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2009-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
213ES0131X
TNDPM0000000524213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3157415OtherBLUE CROSS BLUE SHIELD
TNTN0101OtherAMERICHOICE
TN1454420Medicaid
TN480025490OtherMEDICARE RAILROAD
TNTN0101OtherAMERICHOICE
TN480025490OtherMEDICARE RAILROAD
TNU70511Medicare UPIN