Basic Information
Provider Information | |||||||||
NPI: | 1912202516 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NORTHWEST TENNESSEE FOOT CLINIC, PLLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 600 US HIGHWAY 51 BYP E | ||||||||
Address2: |   | ||||||||
City: | DYERSBURG | ||||||||
State: | TN | ||||||||
PostalCode: | 380242040 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7312873130 | ||||||||
FaxNumber: | 7312873818 | ||||||||
Practice Location | |||||||||
Address1: | 1020 E REELFOOT AVE | ||||||||
Address2: |   | ||||||||
City: | UNION CITY | ||||||||
State: | TN | ||||||||
PostalCode: | 382616051 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7318855131 | ||||||||
FaxNumber: | 7318855335 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/13/2011 | ||||||||
LastUpdateDate: | 01/13/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LU | ||||||||
AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
AuthorizedOfficialMiddleName: | T | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER/PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 7312873130 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | DPM | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0131X | 0000000658 | TN | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot Surgery |
No ID Information.