Provider Demographics
NPI:1467879684
Name:WHITE BEAR FOOT AND ANKLE CLINIC INC
Entity Type:Organization
Organization Name:WHITE BEAR FOOT AND ANKLE CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:M
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:651-426-3995
Mailing Address - Street 1:4653 WHITE BEAR PKWY
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-3300
Mailing Address - Country:US
Mailing Address - Phone:651-426-3995
Mailing Address - Fax:651-426-5626
Practice Address - Street 1:4653 WHITE BEAR PKWY
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-3300
Practice Address - Country:US
Practice Address - Phone:651-426-3995
Practice Address - Fax:651-426-5626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-26
Last Update Date:2014-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN472603200Medicaid
MNH100139355Medicare PIN
MN7217560001Medicare NSC