Provider Demographics
NPI:1144342338
Name:GERIATRIC FOOT CARE OF W VIR
Entity type:Organization
Organization Name:GERIATRIC FOOT CARE OF W VIR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:R
Authorized Official - Last Name:FOLICKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:502-724-0900
Mailing Address - Street 1:9016 TAYLORSVILLE RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40299-1750
Mailing Address - Country:US
Mailing Address - Phone:502-724-0900
Mailing Address - Fax:
Practice Address - Street 1:2620 FAIRMONT AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-3494
Practice Address - Country:US
Practice Address - Phone:502-724-0900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV00142213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0007469000Medicaid
WVC31093OtherRAILROAD MEDICARE
WVGE9245971Medicare PIN