Provider Demographics
NPI:1043456254
Name:TRUSSVILLE FOOT CARE CENTER PC
Entity type:Organization
Organization Name:TRUSSVILLE FOOT CARE CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:205-661-1400
Mailing Address - Street 1:1930 EDWARDS LAKE RD
Mailing Address - Street 2:SUITE 138
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35235-3718
Mailing Address - Country:US
Mailing Address - Phone:205-661-1400
Mailing Address - Fax:
Practice Address - Street 1:1930 EDWARDS LAKE RD
Practice Address - Street 2:SUITE 138
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35235-3718
Practice Address - Country:US
Practice Address - Phone:205-661-1400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-18
Last Update Date:2008-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL209213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529906320Medicaid
AL529906320Medicaid
ALU67579Medicare UPIN