Basic Information
| Provider Information | |||||||||
| NPI: | 1194909556 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE FOOT INSTITUTE, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PHYSICIANS FOOTCARE, LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1730 ST JULIAN PLACE | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292042044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032566776 | ||||||||
| FaxNumber: | 8032566778 | ||||||||
| Practice Location | |||||||||
| Address1: | 1730 SAINT JULIAN PL | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032566776 | ||||||||
| FaxNumber: | 8032566778 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2007 | ||||||||
| LastUpdateDate: | 01/08/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RAY | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8032566776 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DPM | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 213ES0103X | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | GP9909 | 05 | SC | MEDICAID | DN1264 | 01 | SC | MEDICARE RR | OTHER |