Basic Information
Provider Information | |||||||||
NPI: | 1801006986 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | RAPIDS FOOT CARE CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 311 8TH ST S | ||||||||
Address2: |   | ||||||||
City: | WISCONSIN RAPIDS | ||||||||
State: | WI | ||||||||
PostalCode: | 544944622 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7154238637 | ||||||||
FaxNumber: | 7154242724 | ||||||||
Practice Location | |||||||||
Address1: | 311 8TH ST S | ||||||||
Address2: |   | ||||||||
City: | WISCONSIN RAPIDS | ||||||||
State: | WI | ||||||||
PostalCode: | 544944622 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7154238637 | ||||||||
FaxNumber: | 7154242724 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/23/2007 | ||||||||
LastUpdateDate: | 01/25/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HARDIMAN | ||||||||
AuthorizedOfficialFirstName: | PATRIC | ||||||||
AuthorizedOfficialMiddleName: | J. | ||||||||
AuthorizedOfficialTitleorPosition: | PHYSICIAN/OWNER | ||||||||
AuthorizedOfficialTelephone: | 7154238637 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0131X | 678-025 | WI | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot Surgery |
ID Information
ID | Type | State | Issuer | Description | 43218500 | 05 | WI |   | MEDICAID |