Provider Demographics
NPI:1649387424
Name:FOOT AND ANKLE CLINIC, PC
Entity Type:Organization
Organization Name:FOOT AND ANKLE CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KHAM
Authorized Official - Middle Name:VAY
Authorized Official - Last Name:UNG
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:712-255-0502
Mailing Address - Street 1:1502 PIERCE ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51105-1246
Mailing Address - Country:US
Mailing Address - Phone:712-255-0502
Mailing Address - Fax:712-258-9977
Practice Address - Street 1:1502 PIERCE ST
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51105-1246
Practice Address - Country:US
Practice Address - Phone:712-255-0502
Practice Address - Fax:712-258-9977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00505213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6800690Medicaid
SD6800454Medicaid
IA0476317Medicaid
SD6800700Medicaid
NE=========00Medicaid
SDS40585Medicare PIN
IAI8890Medicare PIN
NE=========00Medicaid
IA3952040001Medicare NSC
U78753Medicare UPIN
IA0476317Medicaid
NE098749Medicare PIN