Provider Demographics
NPI:1649409756
Name:ST. AUGUSTINE FOOT & ANKLE, INC
Entity Type:Organization
Organization Name:ST. AUGUSTINE FOOT & ANKLE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:LEBEAU
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:904-824-0869
Mailing Address - Street 1:1 SAINT JOHNS MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-5300
Mailing Address - Country:US
Mailing Address - Phone:904-824-0869
Mailing Address - Fax:904-826-0966
Practice Address - Street 1:1 SAINT JOHNS MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5300
Practice Address - Country:US
Practice Address - Phone:904-824-0869
Practice Address - Fax:904-826-0966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-09
Last Update Date:2023-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Single Specialty
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001262300Medicaid
FL6500EOtherBLUE CROSS AND BLUE SHIELD OF FLORIDA
FL001262300Medicaid
FLCK683ZMedicare PIN