Provider Demographics
NPI:1396874285
Name:BRUNSWICK FOOT & ANKLE SURGERY
Entity type:Organization
Organization Name:BRUNSWICK FOOT & ANKLE SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:KIBLER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:919-751-9120
Mailing Address - Street 1:14 DOCTORS CIR
Mailing Address - Street 2:SUITE 2
Mailing Address - City:SUPPLY
Mailing Address - State:NC
Mailing Address - Zip Code:28462-4097
Mailing Address - Country:US
Mailing Address - Phone:919-751-9120
Mailing Address - Fax:919-751-9170
Practice Address - Street 1:14 DOCTORS CIR
Practice Address - Street 2:SUITE 2
Practice Address - City:SUPPLY
Practice Address - State:NC
Practice Address - Zip Code:28462-4097
Practice Address - Country:US
Practice Address - Phone:919-751-9120
Practice Address - Fax:919-751-9170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC452213ES0103X
261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890806XMedicaid
NC5199990001OtherMEDICARE DMERC PTAN
NC2339324Medicare PIN
NC890806XMedicaid
NCU87970Medicare UPIN