Provider Demographics
NPI:1922043140
Name:SOUTH BALDWIN PODIATRY, P.C.
Entity Type:Organization
Organization Name:SOUTH BALDWIN PODIATRY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KERI
Authorized Official - Middle Name:
Authorized Official - Last Name:KRAFT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-943-3668
Mailing Address - Street 1:1770 N ALSTON ST
Mailing Address - Street 2:
Mailing Address - City:FOLEY
Mailing Address - State:AL
Mailing Address - Zip Code:36535-2274
Mailing Address - Country:US
Mailing Address - Phone:251-943-3668
Mailing Address - Fax:251-943-3314
Practice Address - Street 1:1770 N ALSTON ST
Practice Address - Street 2:
Practice Address - City:FOLEY
Practice Address - State:AL
Practice Address - Zip Code:36535-2274
Practice Address - Country:US
Practice Address - Phone:251-943-3668
Practice Address - Fax:251-943-3314
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2013-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL244213E00000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529908470Medicaid
ALU85663Medicare UPIN
4269840001Medicare NSC
ALDG0469Medicare PIN
AL529908470Medicaid
051503119Medicare ID - Type UnspecifiedDEBRA M. GIBSON, DPM