Provider Demographics
NPI:1568400216
Name:ST JOSEPH FOOT CLINIC LLC
Entity Type:Organization
Organization Name:ST JOSEPH FOOT CLINIC LLC
Other - Org Name:ST JOSEPH FOOT CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INSURANCE CLERK
Authorized Official - Prefix:MISS
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:PMAC
Authorized Official - Phone:816-364-2338
Mailing Address - Street 1:1005A W SAINT MAARTENS DR
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-2989
Mailing Address - Country:US
Mailing Address - Phone:816-364-2338
Mailing Address - Fax:816-364-1003
Practice Address - Street 1:1005A W SAINT MAARTENS DR
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-2989
Practice Address - Country:US
Practice Address - Phone:816-364-2338
Practice Address - Fax:816-364-1003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO5648250001Medicare NSC
MOW230000Medicare PIN