Provider Demographics
NPI:1447429089
Name:FOOT AND WOUND INSTITUTE OF THE SOUTH
Entity type:Organization
Organization Name:FOOT AND WOUND INSTITUTE OF THE SOUTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GERARD
Authorized Official - Middle Name:
Authorized Official - Last Name:GUERIN
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:985-345-6616
Mailing Address - Street 1:157 SELLERS HWY
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:MS
Mailing Address - Zip Code:39654
Mailing Address - Country:US
Mailing Address - Phone:601-362-3158
Mailing Address - Fax:
Practice Address - Street 1:157 FE SELLERS HIGHWAY
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MS
Practice Address - Zip Code:39654
Practice Address - Country:US
Practice Address - Phone:601-362-3158
Practice Address - Fax:318-336-4052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-28
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS80070261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1323462Medicaid
MS00015989Medicaid
MS=========BOtherBCBS
LA56020Medicare PIN