=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457839839
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUPERIOR PODIATRY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/30/2018
-----------------------------------------------------
Last Update Date | 11/05/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1690 US HIGHWAY 1 S STE C
-----------------------------------------------------
City | SAINT AUGUSTINE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32084-6024
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-436-8001
-----------------------------------------------------
Fax | 904-377-6776
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1690 US HIGHWAY 1 S STE C
-----------------------------------------------------
City | SAINT AUGUSTINE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32084-6024
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-436-8001
-----------------------------------------------------
Fax | 904-377-6776
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | DR. JOHN RANDALL NORTHRUP
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 904-436-8001
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------