MEDICARE: MID-SOUTH PODIATRY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP1100X	Podiatric Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1942497854
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MID-SOUTH PODIATRY, LLC

Provider Business Mailing Address
First Line	:	3203 CARRINGTON LN
Second Line	:
City	:	COLUMBIA
State	:	TN
Zip	:	38401-8645
Country	:	US
Telephone Number	:	931-629-7176
Fax Number	:	931-223-5459

Provider Business Practice Location Address
First Line	:	1950 PICKWICK ST
Second Line	:
City	:	SAVANNAH
State	:	TN
Zip	:	38372-5309
Country	:	US
Telephone Number	:	931-629-7176
Fax Number	:	931-223-5459

Authorized Official
Title or Position	:	DOCTOR
Name	:	AARON M OWENS
Credential	:	DPM
Telephone Number	:	931-629-7176

Provider Enumeration Date	:	09/25/2007
Last Update Date	:	05/14/2009

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