Provider Demographics
NPI:1295773398
Name:MERIDIAN FOOT CLINIC INC
Entity type:Organization
Organization Name:MERIDIAN FOOT CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OF CORPORATION
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:HINES
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:405-751-6152
Mailing Address - Street 1:13301 N MERIDIAN
Mailing Address - Street 2:BLDG 700 SUITE 701
Mailing Address - City:OKLA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-9369
Mailing Address - Country:US
Mailing Address - Phone:405-751-6152
Mailing Address - Fax:405-752-5158
Practice Address - Street 1:13301 N MERIDIAN
Practice Address - Street 2:BLDG 700 SUITE 701
Practice Address - City:OKLA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-9369
Practice Address - Country:US
Practice Address - Phone:405-751-6152
Practice Address - Fax:405-752-5158
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK113213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1023011616OtherINDIVIDUAL NPI
=========001OtherBLUE CROSS BLUE SHIELD
OK0764240001Medicare NSC
T40750Medicare UPIN