Provider Demographics
NPI:1689683666
Name:PHYSICIANS FOOTCARE ORANGEBURG LLC
Entity Type:Organization
Organization Name:PHYSICIANS FOOTCARE ORANGEBURG LLC
Other - Org Name:CAROLINA FOOT INSTITUTE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:RAY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:803-531-2888
Mailing Address - Street 1:718 BROUGHTON ST
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29115-6648
Mailing Address - Country:US
Mailing Address - Phone:803-531-2888
Mailing Address - Fax:803-531-2813
Practice Address - Street 1:718 BROUGHTON ST
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29115
Practice Address - Country:US
Practice Address - Phone:803-531-2888
Practice Address - Fax:803-531-2813
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-07
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC570213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDF2229OtherRETIRED RAILROAD MEDICARE
SC5789720001Medicare NSC
SC8559Medicare PIN