MEDICARE: TRI LAKES PODIATRY PC

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	213E00000X	Podiatrist	2000165040	MO

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00294967	OTHER	MO	RAILROAD MEDICARE

General Provider Information

NPI Number	:	1275758351
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRI LAKES PODIATRY PC

Provider Business Mailing Address
First Line	:	PO BOX 870
Second Line	:	300 WEST MT VERNON SUITE G
City	:	NIXA
State	:	MO
Zip	:	65714-0870
Country	:	US
Telephone Number	:	417-725-9995
Fax Number	:	417-725-2985

Provider Business Practice Location Address
First Line	:	105 S RIDGECREST AVE
Second Line	:
City	:	NIXA
State	:	MO
Zip	:	65714-7807
Country	:	US
Telephone Number	:	417-724-3100
Fax Number	:	417-725-2985

Authorized Official
Title or Position	:	OWNER DOCTOR
Name	:	JEFFREY P KORTE
Credential	:	DPM
Telephone Number	:	417-725-9995

Provider Enumeration Date	:	04/16/2007
Last Update Date	:	08/22/2020

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