Provider Demographics
NPI:1720032816
Name:MARK R KUTYLA DPM PA
Entity Type:Organization
Organization Name:MARK R KUTYLA DPM PA
Other - Org Name:MIDLANDS FOOT CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:R
Authorized Official - Last Name:KUTYLA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:803-356-4712
Mailing Address - Street 1:121 PARK PLACE CT
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072-6690
Mailing Address - Country:US
Mailing Address - Phone:803-356-4712
Mailing Address - Fax:803-356-0832
Practice Address - Street 1:121 PARK PLACE CT
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-6690
Practice Address - Country:US
Practice Address - Phone:803-356-4712
Practice Address - Fax:803-356-0832
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARK R KUTYLA DPM PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-22
Last Update Date:2011-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC516213EP1101X, 213ER0200X, 213ES0000X, 213ES0131X, 2471M1202X, 332B00000X, 332BC3200X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
No213ER0200XPodiatric Medicine & Surgery Service ProvidersPodiatristRadiologyGroup - Single Specialty
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports MedicineGroup - Single Specialty
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
No2471M1202XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistMagnetic Resonance ImagingGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No335E00000XSuppliersProsthetic/Orthotic SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC7238051OtherAETNA PROVIDER NO.
SC1020003OtherACM # MIDLANDS FOOT CL.
SC42D2021725OtherCLIA CERTIFICATE OF WAIVER
SC1020003OtherACM # MIDLANDS FOOT CL.
SC42D2021725OtherCLIA CERTIFICATE OF WAIVER
SCU743960281Medicare PIN