Basic Information
| Provider Information | |||||||||
| NPI: | 1417980400 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ASSOCIATED FOOT AND ANKLE CLINICS PSC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1830 DESTINY LN | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 42104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708463338 | ||||||||
| FaxNumber: | 2708463318 | ||||||||
| Practice Location | |||||||||
| Address1: | 1830 DESTINY LN | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 42104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708463338 | ||||||||
| FaxNumber: | 2708463318 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 07/08/2013 | ||||||||
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| AuthorizedOfficialLastName: | YOUNG | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
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| AuthorizedOfficialTitleorPosition: | DPM OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2708463338 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DPM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | 230 | KY | N | Suppliers | Durable Medical Equipment & Medical Supplies | 213E00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | DF9516 | 01 | KY | RAILROAD MEDICARE | OTHER | 90004391 | 01 | KY | MEDICAID DME | OTHER | 80900319 | 05 | KY | MEDICAID |