Healthcare Provider Details

I. General information

NPI: 1780605055
Provider Name (Legal Business Name): RIVERSIDE PODIATRY CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 06/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 W KEM RD
MARION IN
46952-1548
US

IV. Provider business mailing address

1900 W KEM RD
MARION IN
46952-1548
US

V. Phone/Fax

Practice location:
  • Phone: 765-664-0107
  • Fax: 765-664-6541
Mailing address:
  • Phone: 765-664-0107
  • Fax: 765-664-6541

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number07000307
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DR. GARY LYNN ADSIT
Title or Position: OWNER
Credential: DPM
Phone: 765-664-0107