Provider Demographics
NPI:1902177967
Name:FOOTSEAS MEDICAL INC
Entity Type:Organization
Organization Name:FOOTSEAS MEDICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SHERRELL
Authorized Official - Middle Name:R
Authorized Official - Last Name:WILKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:850-267-4554
Mailing Address - Street 1:2441 US HIGHWAY 98 W
Mailing Address - Street 2:102
Mailing Address - City:SANTA ROSA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32459-5385
Mailing Address - Country:US
Mailing Address - Phone:850-267-4554
Mailing Address - Fax:850-267-4539
Practice Address - Street 1:2441 US HIGHWAY 98 W
Practice Address - Street 2:102
Practice Address - City:SANTA ROSA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32459-5385
Practice Address - Country:US
Practice Address - Phone:850-267-4554
Practice Address - Fax:850-267-4539
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-23
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO1645213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLT95185Medicare UPIN