SMOKY MOUNTAIN FOOT CLINIC PA

Provider Demographics

• NPI: 1629168968
• Name: SMOKY MOUNTAIN FOOT CLINIC PA
• Entity Type: Organization
• Organization Name: SMOKY MOUNTAIN FOOT CLINIC PA
• Authorized Official - Title/Position: CEO
• Authorized Official - First Name: WILLIAM
• Authorized Official - Middle Name: D
• Authorized Official - Last Name: BANKS
• Authorized Official - Credentials: DPM
• Authorized Official - Phone: 828-452-4343
• Mailing Address - Street 1: PO BOX 278
• Mailing Address - City: CLYDE
• Mailing Address - State: NC
• Mailing Address - Zip Code: 28721-0278
• Mailing Address - Country: US
• Mailing Address - Phone: 828-452-4343
• Mailing Address - Fax: 828-452-1477
• Practice Address - Street 1: 188 GEORGIA RD
• Practice Address - City: FRANKLIN
• Practice Address - State: NC
• Practice Address - Zip Code: 28734-3246
• Practice Address - Country: US
• Practice Address - Phone: 828-452-4343
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2006-10-16
• Last Update Date: 2015-11-24

Provider Licenses

State	License ID	Taxonomies
NC	301	213E00000X, 213ES0131X
NC	346	213E00000X, 213ES0131X
NC	469	213E00000X, 213ES0103X
NC	563	213E00000X, 213ES0131X
NC	547	213E00000X, 213ES0131X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization	Group
Yes	213E00000X	Podiatric Medicine & Surgery Service Providers	Podiatrist		Group - Single Specialty
No	213ES0103X	Podiatric Medicine & Surgery Service Providers	Podiatrist	Foot & Ankle Surgery	Group - Single Specialty
No	213ES0131X	Podiatric Medicine & Surgery Service Providers	Podiatrist	Foot Surgery	Group - Single Specialty

Provider Identifiers

State	Identifier ID	ID Type	Issuer
NC	5911410	Medicaid
NC	0801K	Other	BCBS
NC	890801K	Medicaid
NC	890806B	Medicaid
NC	890808P	Medicaid
NC	0800A	Other	BCBS
NC	0808P	Other	BCBS
NC	0806B	Other	BCBS
NC	890800A	Medicaid
NC	0806B	Other	BCBS
NC	890806B	Medicaid
NC	890800A	Medicaid
NC	0571680006	Medicare NSC
NC	0808P	Other	BCBS
	U13002	Medicare UPIN
	2432485B	Medicare ID - Type Unspecified
NC	5911410	Medicaid
	U63367	Medicare UPIN