MEDICARE: ST. MATTHEWS FOOT AND ANKLE CLINIC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332BC3200X	Customized Equipment (DME)	195	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000290617	OTHER	KY	BLUECROSS

General Provider Information

NPI Number	:	1083662704
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST. MATTHEWS FOOT AND ANKLE CLINIC

Provider Business Mailing Address
First Line	:	117 S HUBBARDS LN
Second Line	:	SUITE 102
City	:	LOUISVILLE
State	:	KY
Zip	:	40207-3937
Country	:	US
Telephone Number	:	270-433-5806
Fax Number	:	270-433-2443

Provider Business Practice Location Address
First Line	:	117 S HUBBARDS LN
Second Line	:	SUITE 102
City	:	LOUISVILLE
State	:	KY
Zip	:	40207-3937
Country	:	US
Telephone Number	:	270-433-5806
Fax Number	:	270-433-2443

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	CINDY SHOOPMAN
Credential	:
Telephone Number	:	270-433-5806

Provider Enumeration Date	:	05/05/2006
Last Update Date	:	12/02/2009

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