Provider Demographics
NPI:1760560015
Name:UNIVERSITY FOOT AND ANKLE CENTER LLC
Entity Type:Organization
Organization Name:UNIVERSITY FOOT AND ANKLE CENTER LLC
Other - Org Name:LOUISVILLE FOOT AND ANKLE SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:CHILDRESS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:502-893-1844
Mailing Address - Street 1:3 AUDUBON PLAZA DR STE 320
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40217-1319
Mailing Address - Country:US
Mailing Address - Phone:502-893-1844
Mailing Address - Fax:
Practice Address - Street 1:3 AUDUBON PLAZA DR STE 320
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217-1319
Practice Address - Country:US
Practice Address - Phone:502-893-1844
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY00209261QP1100X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100000180Medicaid
KY7100439680Medicaid
KY6037840001Medicare NSC
KY00334Medicare PIN
KY7100000180Medicaid