Provider Demographics
NPI:1184885147
Name:MISSISSIPPI FOOT CLINIC, INC
Entity type:Organization
Organization Name:MISSISSIPPI FOOT CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIE
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:SR
Authorized Official - Credentials:DPM
Authorized Official - Phone:601-355-0026
Mailing Address - Street 1:PO BOX 10529
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39289-0529
Mailing Address - Country:US
Mailing Address - Phone:601-355-0026
Mailing Address - Fax:601-355-0069
Practice Address - Street 1:128 POINDEXTER ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39203-3048
Practice Address - Country:US
Practice Address - Phone:601-355-0026
Practice Address - Fax:601-355-0069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-23
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS80062213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MST20901Medicare UPIN