Provider Demographics
NPI:1457480683
Name:WOLF RIVER FAMILY FOOTCARE PLLC
Entity Type:Organization
Organization Name:WOLF RIVER FAMILY FOOTCARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:SICILIANO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:901-381-2800
Mailing Address - Street 1:7424 US HIGHWAY 64
Mailing Address - Street 2:SUITE 119
Mailing Address - City:BARTLETT
Mailing Address - State:TN
Mailing Address - Zip Code:38133-3986
Mailing Address - Country:US
Mailing Address - Phone:901-381-2800
Mailing Address - Fax:901-381-2677
Practice Address - Street 1:7424 US HIGHWAY 64
Practice Address - Street 2:SUITE 119
Practice Address - City:BARTLETT
Practice Address - State:TN
Practice Address - Zip Code:38133-3986
Practice Address - Country:US
Practice Address - Phone:901-381-2800
Practice Address - Fax:901-381-2677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDPM0000000422213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNDG7179OtherMEDICARE ID TYPE UNSPECIFIED
TNDG7179OtherMEDICARE ID TYPE UNSPECIFIED
6041020001Medicare NSC