Provider Demographics
NPI:1821153636
Name:MID-WEST PODIATRY & ASSOCIATES, LLC
Entity Type:Organization
Organization Name:MID-WEST PODIATRY & ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:PIKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-432-1903
Mailing Address - Street 1:11709 OLD BALLAS RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:CREVE COEUR
Mailing Address - State:MO
Mailing Address - Zip Code:63141-7029
Mailing Address - Country:US
Mailing Address - Phone:314-432-1903
Mailing Address - Fax:314-432-5105
Practice Address - Street 1:11709 OLD BALLAS RD
Practice Address - Street 2:SUITE 201
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-7029
Practice Address - Country:US
Practice Address - Phone:314-432-1903
Practice Address - Fax:314-432-5105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-22
Last Update Date:2009-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO365905413Medicaid
MO365906405Medicaid
MO365906405Medicaid
MO365905413Medicaid