SMOKY MOUNTAIN FOOT CLINIC PA

Provider Demographics

• NPI: 1205911906
• Name: SMOKY MOUNTAIN FOOT CLINIC PA
• Entity type: Organization
• Organization Name: SMOKY MOUNTAIN FOOT CLINIC PA
• Authorized Official - Title/Position: CEO
• Authorized Official - First Name: WILLIAM
• Authorized Official - Middle Name: D
• Authorized Official - Last Name: BANKS
• Authorized Official - Credentials: DPM
• Authorized Official - Phone: 828-452-4343
• Mailing Address - Street 1: PO BOX 278
• Mailing Address - City: CLYDE
• Mailing Address - State: NC
• Mailing Address - Zip Code: 28721-0278
• Mailing Address - Country: US
• Mailing Address - Phone: 828-452-4343
• Mailing Address - Fax: 828-452-1477
• Practice Address - Street 1: 573 MERRIMON AVE
• Practice Address - City: ASHEVILLE
• Practice Address - State: NC
• Practice Address - Zip Code: 28804-3490
• Practice Address - Country: US
• Practice Address - Phone: 828-254-7716
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2006-10-25
• Last Update Date: 2011-11-09

Provider Licenses

State	License ID	Taxonomies
NC	346	213E00000X
NC	B01	213E00000X
NC	380	213E00000X
NC	469	213E00000X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization	Group
Yes	213E00000X	Podiatric Medicine & Surgery Service Providers	Podiatrist		Group - Single Specialty

Provider Identifiers

State	Identifier ID	ID Type	Issuer
	0808P	Other	BCBS
NC	89086B	Medicaid
NC	0807K	Other	BCBS
NC	5911409	Medicaid
NC	890801K	Medicaid
NC	890808P	Medicaid
NC	0800A	Other	BCBS
NC	0806B	Other	BCBS
NC	890800A	Medicaid
NC	2432623A	Medicare PIN
NC	0806B	Other	BCBS
	U63367	Medicare UPIN
	2431981E	Medicare ID - Type Unspecified
	0808P	Other	BCBS
	U44307	Medicare UPIN
NC	890801K	Medicaid
	2432485B	Medicare ID - Type Unspecified
NC	89086B	Medicaid
NC	DA9077	Medicare PIN
NC	0800A	Other	BCBS
NC	0571680001	Medicare NSC