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General NPI Number Information
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NPI Number | 1457543589
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Entity Type | Organization
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Legal Business Name | MID-CAROLINA PODIATRY, INC.
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Dates
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Enumeration Date | 08/13/2007
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Last Update Date | 04/10/2008
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Provider Practice Location Address
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Address Line | 1207 N LAKE DR
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City | LEXINGTON
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State | SC
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Zip | 29072-7647
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Country | US
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Telephone | 803-359-5435
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Fax | 803-359-4502
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Provider Business Mailing Address
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Address Line | 1207 N LAKE DR
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City | LEXINGTON
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State | SC
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Zip | 29072-7647
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Country | US
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Telephone | 803-359-5435
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Fax | 803-359-4502
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Authorized Official
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Title or Position | PRESIDENT
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Name | PAUL R BEARDEN
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Credential | D.P.M.
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Telephone | 803-359-5435
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213ES0131X
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Taxonomy Name | Foot Surgery Podiatrist
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License Number | 00130
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License Number State | SC
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Taxonomy #2
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Taxonomy Code | 335E00000X
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Taxonomy Name | Prosthetic/Orthotic Supplier
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License Number | 00130
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License Number State | SC
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Taxonomy #3
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Taxonomy Code | 332BC3200X
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Taxonomy Name | Customized Equipment (DME)
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License Number | 00130
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License Number State | SC
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