Provider Demographics
NPI:1558556225
Name:JASPER PODIATRY CENTER, P.C.
Entity Type:Organization
Organization Name:JASPER PODIATRY CENTER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:S
Authorized Official - Last Name:ODLE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:205-924-4474
Mailing Address - Street 1:804 20TH AVE E
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:AL
Mailing Address - Zip Code:35501-4024
Mailing Address - Country:US
Mailing Address - Phone:120-538-4447
Mailing Address - Fax:205-384-4588
Practice Address - Street 1:1800 BIRMINGHAM AVE
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:AL
Practice Address - Zip Code:35501-5461
Practice Address - Country:US
Practice Address - Phone:205-384-4474
Practice Address - Fax:205-384-4428
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-06
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL157261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL480034067OtherRAILROAD MEDICARE
ALU58040OtherUPIN
AL051176296OtherBLUE CROSS AND BLUE SHIELD OF ALABAMA
AL157OtherLICENSE NUMBER
AL000076296Medicare PIN