Basic Information
| Provider Information | |||||||||
| NPI: | 1902946387 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TESSON FERRY FOOT AND ANKLE, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ALTON FOOT AND ANKLE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2315 DOUGHERTY FERRY RD | ||||||||
| Address2: | STE 110 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631223383 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149091920 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3505 COLLEGE AVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | ALTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620025065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184629695 | ||||||||
| FaxNumber: | 6184629651 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2007 | ||||||||
| LastUpdateDate: | 06/09/2010 | ||||||||
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| AuthorizedOfficialLastName: | BARTH | ||||||||
| AuthorizedOfficialFirstName: | LINDSAY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3149091920 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | TESSON FERRY FOOT AND ANKLE, INC. | ||||||||
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| AuthorizedOfficialCredential: | DPM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
No ID Information.