MEDICARE: OLIVER FOOT CLINIC, INC.

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	213ES0131X	Foot Surgery Podiatrist
2	213ES0131X	Foot Surgery Podiatrist	DPM0000000524	TN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	480025490	OTHER	TN	MEDICARE RAILROAD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3157415	OTHER	TN	BLUE CROSS BLUE SHIELD
2	TN0101	OTHER	TN	AMERICHOICE
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1437297595
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OLIVER FOOT CLINIC, INC.

Provider Business Mailing Address
First Line	:	P.O. BOX 766
Second Line	:
City	:	SHELBYVILLE
State	:	TN
Zip	:	37162-0766
Country	:	US
Telephone Number	:	931-684-8884
Fax Number	:	931-684-8808

Provider Business Practice Location Address
First Line	:	635 N. MAIN STREET
Second Line	:	SUITE A
City	:	SHELBYVILLE
State	:	TN
Zip	:	37160-3235
Country	:	US
Telephone Number	:	931-684-8884
Fax Number	:	931-684-8808

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	DR. RUSSELL WADE OLIVER
Credential	:	DPM
Telephone Number	:	931-684-8884

Provider Enumeration Date	:	02/01/2007
Last Update Date	:	12/29/2009

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Directions to “OLIVER FOOT CLINIC, INC. ” Practice Location

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