=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134413834
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UNIVERSITY PODIATRIC SURGERY AND LIMB PRESERVATION PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/31/2011
-----------------------------------------------------
Last Update Date | 05/23/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 401 E CHESTNUT ST SUITE 710
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40202-5707
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-583-8303
-----------------------------------------------------
Fax | 502-583-2051
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 401 E CHESTNUT ST SUITE 710
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40202-5707
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-583-8303
-----------------------------------------------------
Fax | 502-583-2051
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ADAM B HICKS
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 502-583-8303
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | 00317
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------