Provider Demographics
NPI:1447355755
Name:SMOKY MOUNTAIN FOOT CLINIC PA
Entity type:Organization
Organization Name:SMOKY MOUNTAIN FOOT CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:D
Authorized Official - Last Name:BANKS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:828-452-4343
Mailing Address - Street 1:PO BOX 278
Mailing Address - Street 2:
Mailing Address - City:CLYDE
Mailing Address - State:NC
Mailing Address - Zip Code:28721-0278
Mailing Address - Country:US
Mailing Address - Phone:828-452-4343
Mailing Address - Fax:828-452-1477
Practice Address - Street 1:289 ACCESS RD
Practice Address - Street 2:
Practice Address - City:WAYNESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28785-9006
Practice Address - Country:US
Practice Address - Phone:828-452-4343
Practice Address - Fax:828-452-1477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2015-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC301213E00000X, 213ES0131X
NC346213E00000X, 213ES0131X
NC469213E00000X, 213ES0103X
NC547213E00000X, 213ES0131X
NC563213E00000X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0800AOtherBCBS
NC0801KOtherBCBS
NC0806BOtherBCBS
NC0808POtherBCBS
NC890800AMedicaid
NC890808PMedicaid
NC2432485BMedicare PIN
NC0801KOtherBCBS
NC2433053CMedicare PIN
NC0808POtherBCBS
U13002Medicare UPIN
NC0806BOtherBCBS
NC2432623BMedicare PIN
NCDA9077Medicare PIN
NC2433653Medicare PIN
NCC12474Medicare PIN
NC0800AOtherBCBS
NC2431981EMedicare PIN