Provider Demographics
NPI:1609041086
Name:BODY-MIND-SPIRIT PODIATRIC CENTER, PLLC
Entity Type:Organization
Organization Name:BODY-MIND-SPIRIT PODIATRIC CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:606-324-3668
Mailing Address - Street 1:500 14TH ST
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41101-2622
Mailing Address - Country:US
Mailing Address - Phone:606-324-3668
Mailing Address - Fax:
Practice Address - Street 1:500 14TH ST
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-2622
Practice Address - Country:US
Practice Address - Phone:606-324-3668
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-25
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY00305213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY80000540Medicaid
KY9001061200Medicaid
OH2549086Medicaid
WV3810002375Medicaid
KY80000540Medicaid
KY1962601Medicare PIN
OH2549086Medicaid
KY5390720001Medicare NSC