Provider Demographics
NPI:1679568919
Name:M & L PODIATRY PA
Entity type:Organization
Organization Name:M & L PODIATRY PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:KILLIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:704-847-9788
Mailing Address - Street 1:534 W JOHN ST
Mailing Address - Street 2:STE 100
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28105-5353
Mailing Address - Country:US
Mailing Address - Phone:704-847-9788
Mailing Address - Fax:704-849-2928
Practice Address - Street 1:534 W JOHN ST
Practice Address - Street 2:STE 100
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-5353
Practice Address - Country:US
Practice Address - Phone:704-847-9788
Practice Address - Fax:704-849-2928
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-13
Last Update Date:2011-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC312213E00000X
NC367213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890156XMedicaid
NC2432792Medicare PIN
NC1257370001Medicare NSC