Provider Demographics
NPI:1821393422
Name:NORTHWEST TENNESSEE FOOT CLINIC, PLLC
Entity Type:Organization
Organization Name:NORTHWEST TENNESSEE FOOT CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:T
Authorized Official - Last Name:LU
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:731-287-3130
Mailing Address - Street 1:600 US HIGHWAY 51 BYP E
Mailing Address - Street 2:
Mailing Address - City:DYERSBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38024-2040
Mailing Address - Country:US
Mailing Address - Phone:731-287-3130
Mailing Address - Fax:731-287-3818
Practice Address - Street 1:326 ASBURY AVE
Practice Address - Street 2:SUITE #102
Practice Address - City:RIPLEY
Practice Address - State:TN
Practice Address - Zip Code:38063-5577
Practice Address - Country:US
Practice Address - Phone:731-221-2567
Practice Address - Fax:731-221-2560
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-13
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000658213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN6409830003Medicare NSC