=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669604047
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OFFUTT FOOT AND ANKLE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2009
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1106 S A ST
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47374-5526
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-965-3668
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1380 CHESTER BLVD SUITE C
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47374-1907
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-965-3668
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT DIRECTOR
-----------------------------------------------------
Name | DR. STEPHEN M OFFUTT
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 765-965-3668
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | 07000991A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------