Provider Demographics
NPI:1134413834
Name:UNIVERSITY PODIATRIC SURGERY AND LIMB PRESERVATION PLLC
Entity type:Organization
Organization Name:UNIVERSITY PODIATRIC SURGERY AND LIMB PRESERVATION PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:B
Authorized Official - Last Name:HICKS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:502-583-8303
Mailing Address - Street 1:401 E CHESTNUT ST
Mailing Address - Street 2:SUITE 710
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-5707
Mailing Address - Country:US
Mailing Address - Phone:502-583-8303
Mailing Address - Fax:502-583-2051
Practice Address - Street 1:401 E CHESTNUT ST
Practice Address - Street 2:SUITE 710
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-5707
Practice Address - Country:US
Practice Address - Phone:502-583-8303
Practice Address - Fax:502-583-2051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-31
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY335E00000X
KY00317213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No335E00000XSuppliersProsthetic/Orthotic SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100169670Medicaid
KYK014190Medicare PIN
KY6612840001Medicare NSC