Provider Demographics
NPI:1942256490
Name:SOUTWEST PODIATRY, P.C.
Entity Type:Organization
Organization Name:SOUTWEST PODIATRY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:AKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:276-228-2212
Mailing Address - Street 1:680 W MONROE ST
Mailing Address - Street 2:
Mailing Address - City:WYTHEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24382-2240
Mailing Address - Country:US
Mailing Address - Phone:276-228-2212
Mailing Address - Fax:276-228-7835
Practice Address - Street 1:680 W MONROE ST
Practice Address - Street 2:
Practice Address - City:WYTHEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24382-2240
Practice Address - Country:US
Practice Address - Phone:276-228-2212
Practice Address - Fax:276-228-7835
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103000769213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA101905OtherANTHEM GROUP
VA0975940001OtherADMINISTAR FEDERAL
VACI5929OtherRR MEDICARE
VA101905OtherANTHEM GROUP