Basic Information
| Provider Information | |||||||||
| NPI: | 1518938919 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NEXT STEP FOOT AND ANKLE CENTERS, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | TESSON FERRY FOOT AND ANKLE INC. | ||||||||
| OtherOrganizationType: | 4 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3505 COLLEGE AVE | ||||||||
| Address2: | SUITE B | ||||||||
| City: | ALTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620025065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184629695 | ||||||||
| FaxNumber: | 6184629651 | ||||||||
| Practice Location | |||||||||
| Address1: | 3505 COLLEGE AVE | ||||||||
| Address2: | SUITE B | ||||||||
| City: | ALTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620025065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184629695 | ||||||||
| FaxNumber: | 6184629651 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2006 | ||||||||
| LastUpdateDate: | 08/16/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BARTH | ||||||||
| AuthorizedOfficialFirstName: | LINDSAY | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6184629695 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DPM | ||||||||
| NPICertificationDate: | 01/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 213ES0103X | 00724 | MO | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 507004703 | 05 | MO | MEDICAID | 366240000 | 05 | MO | MEDICAID | 506240001 | 05 | MO | MEDICAID |