Provider Demographics
NPI:1457337024
Name:FOOT & ANKLE SPECIALISTS OF RACINE, S.C.
Entity Type:Organization
Organization Name:FOOT & ANKLE SPECIALISTS OF RACINE, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:T
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:262-554-7004
Mailing Address - Street 1:3500 MEACHEM RD
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53405-4662
Mailing Address - Country:US
Mailing Address - Phone:262-554-7004
Mailing Address - Fax:262-554-7004
Practice Address - Street 1:3500 MEACHEM RD
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53405-4662
Practice Address - Country:US
Practice Address - Phone:262-554-7004
Practice Address - Fax:262-554-7004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-15
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI775213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI480032991OtherRAILROAD MEDICARE
WV438857OtherDMERC REGION B
WI82015Medicare ID - Type Unspecified
WI4388570001Medicare NSC