Basic Information
| Provider Information | |||||||||
| NPI: | 1922305564 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MAJOR FOOT AND ANKLE CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 W RAMPART ST | ||||||||
| Address2: | SUITE 160 | ||||||||
| City: | SHELBYVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461768845 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173920003 | ||||||||
| FaxNumber: | 3173981859 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 W RAMPART ST STE 160 | ||||||||
| Address2: | |||||||||
| City: | SHELBYVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461768845 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173920003 | ||||||||
| FaxNumber: | 3173981859 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2011 | ||||||||
| LastUpdateDate: | 05/08/2018 | ||||||||
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| AuthorizedOfficialLastName: | HORNER | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3173923211 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 07001053A | IN | Y | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 200997340 | 05 | IN | MEDICAID |