Provider Demographics
NPI:1790714491
Name:ANKLE AND FOOT CENTERS OF MISSOURI P.C.
Entity Type:Organization
Organization Name:ANKLE AND FOOT CENTERS OF MISSOURI P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AKILIS
Authorized Official - Middle Name:MIKE
Authorized Official - Last Name:THEOHARIDIS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:816-436-7900
Mailing Address - Street 1:407 NE 76TH TER
Mailing Address - Street 2:
Mailing Address - City:GLADSTONE
Mailing Address - State:MO
Mailing Address - Zip Code:64118-1708
Mailing Address - Country:US
Mailing Address - Phone:816-436-7900
Mailing Address - Fax:816-436-0999
Practice Address - Street 1:407 NE 76TH TER
Practice Address - Street 2:
Practice Address - City:GLADSTONE
Practice Address - State:MO
Practice Address - Zip Code:64118-1708
Practice Address - Country:US
Practice Address - Phone:816-436-7900
Practice Address - Fax:816-436-0999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-03
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000747213E00000X
213E00000X, 291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes291U00000XLaboratoriesClinical Medical Laboratory
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO505265009Medicaid
MO365265016Medicaid
CB6768OtherRAILROAD AHN
CB6767OtherRAILROAD
MO365265008Medicaid
MO505265017Medicaid
MOK820000AMedicare PIN
MO505265009Medicaid
MO4238380006Medicare NSC
MO505265017Medicaid