Basic Information
| Provider Information | |||||||||
| NPI: | 1194783233 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PIEDMONT FOOT CLINIC, PA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PIEDMONT FOOT & ANKLE CLINIC, PA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 103 PARKWAY OFFICE COURT | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CARY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275187429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9194813338 | ||||||||
| FaxNumber: | 9194672436 | ||||||||
| Practice Location | |||||||||
| Address1: | 103 PARKWAY OFFICE COURT | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CARY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275187429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9194813338 | ||||||||
| FaxNumber: | 9194672436 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2006 | ||||||||
| LastUpdateDate: | 09/28/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MALICH | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | JAMES | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9194813338 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213EP1101X | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Primary Podiatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 890803A | 05 | NC | MEDICAID | 0803A | 01 | NC | BCBS OF NC GROUP # | OTHER |