=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861691883
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NETTESHEIM FAMILY FOOT CARE, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2007
-----------------------------------------------------
Last Update Date | 05/08/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4305 BUTLER HILL RD SUITE B
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63128-3718
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-849-9009
-----------------------------------------------------
Fax | 314-849-9004
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4305 BUTLER HILL RD STE B
-----------------------------------------------------
City | SAINT LOUIS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63128-3718
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-849-9009
-----------------------------------------------------
Fax | 314-849-9004
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. KEVIN A NETTESHEIM
-----------------------------------------------------
Credential | D.P.M.
-----------------------------------------------------
Telephone | 314-849-9009
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | 000531
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------