Healthcare Provider Details

I. General information

NPI: 1821726464
Provider Name (Legal Business Name): THE FOOT INSTITUTE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2022
Last Update Date: 08/11/2022
Certification Date: 07/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1730 SAINT JULIAN PL
COLUMBIA SC
29204-2410
US

IV. Provider business mailing address

1815 BACK CREEK DR STE 102
CHARLOTTE NC
28213-2159
US

V. Phone/Fax

Practice location:
  • Phone: 803-256-6776
  • Fax:
Mailing address:
  • Phone: 704-716-7820
  • Fax: 704-716-7803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZM0300X
TaxonomyMedical Microbiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: OMAR IDLIBI
Title or Position: PROVIDER
Credential: PATHOLOGIST
Phone: 803-256-6776