Provider Demographics
NPI:1982667366
Name:MID-MISSOURI FOOT AND ANKLE CENTER
Entity Type:Organization
Organization Name:MID-MISSOURI FOOT AND ANKLE CENTER
Other - Org Name:ANDERSON FOOT CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KARA
Authorized Official - Middle Name:
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-341-2971
Mailing Address - Street 1:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65402-0130
Mailing Address - Country:US
Mailing Address - Phone:573-341-2971
Mailing Address - Fax:573-341-8174
Practice Address - Street 1:1210 HOMELIFE PLZ
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-2512
Practice Address - Country:US
Practice Address - Phone:573-341-2971
Practice Address - Fax:573-341-8174
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-07
Last Update Date:2008-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO4456200001Medicare NSC
MO990001664Medicare PIN