Provider Demographics
NPI:1568504371
Name:FOOT SPECIALISTS OF TYLER, PA
Entity Type:Organization
Organization Name:FOOT SPECIALISTS OF TYLER, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:D
Authorized Official - Last Name:RHODUS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:903-592-7200
Mailing Address - Street 1:649 S BROADWAY AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-1602
Mailing Address - Country:US
Mailing Address - Phone:903-592-7200
Mailing Address - Fax:903-592-7211
Practice Address - Street 1:649 S BROADWAY AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-1602
Practice Address - Country:US
Practice Address - Phone:903-592-7200
Practice Address - Fax:903-592-7211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2009-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1375213E00000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXDF6646OtherMEDICARE RAILROAD
TX186188201Medicaid
TX0013PDOtherBCBS
TX0013PDOtherBCBS
TXDF6646OtherMEDICARE RAILROAD
TX186188201Medicaid