Basic Information
| Provider Information | |||||||||
| NPI: | 1821726464 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE FOOT INSTITUTE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1815 BACK CREEK DR STE 102 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282132159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7047167820 | ||||||||
| FaxNumber: | 7047167803 | ||||||||
| Practice Location | |||||||||
| Address1: | 1730 SAINT JULIAN PL | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292042410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032566776 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2022 | ||||||||
| LastUpdateDate: | 08/11/2022 | ||||||||
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| AuthorizedOfficialLastName: | IDLIBI | ||||||||
| AuthorizedOfficialFirstName: | OMAR | ||||||||
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| AuthorizedOfficialTitleorPosition: | PROVIDER | ||||||||
| AuthorizedOfficialTelephone: | 8032566776 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PATHOLOGIST | ||||||||
| NPICertificationDate: | 07/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZM0300X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Medical Microbiology | 207ZP0101X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology | 213ES0103X | Y | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
No ID Information.