Healthcare Provider Details

I. General information

NPI: 1578702320
Provider Name (Legal Business Name): MIDWEST FOOT AND ANKLE CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2009
Last Update Date: 09/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12410 LUSHER RD
SAINT LOUIS MO
63138-1456
US

IV. Provider business mailing address

12410 LUSHER RD
SAINT LOUIS MO
63138-1456
US

V. Phone/Fax

Practice location:
  • Phone: 314-741-3546
  • Fax: 314-741-3548
Mailing address:
  • Phone: 314-741-3546
  • Fax: 314-741-3548

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number2005012314
License Number StateMO

VIII. Authorized Official

Name: DR. FREDERICK MATTHEWS
Title or Position: PODIATRIST
Credential: DPM
Phone: 314-741-3546