Provider Demographics
NPI:1790840080
Name:PREMIER FOOT CLINIC PC
Entity Type:Organization
Organization Name:PREMIER FOOT CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEFANIE
Authorized Official - Middle Name:MONIQUE
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:601-926-1500
Mailing Address - Street 1:705 HIGHWAY 80 W
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39056-4103
Mailing Address - Country:US
Mailing Address - Phone:601-926-1500
Mailing Address - Fax:601-926-1502
Practice Address - Street 1:705 HIGHWAY 80 W
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MS
Practice Address - Zip Code:39056-4103
Practice Address - Country:US
Practice Address - Phone:601-926-1500
Practice Address - Fax:601-926-1502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS80151213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06981282Medicaid
U74485Medicare UPIN
MS5578330001Medicare NSC