1285015578 NPI number — FOOT AND ANKLE PAIN CLINIC CORPORATION

Table of content: (NPI 1285015578)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285015578 NPI number — FOOT AND ANKLE PAIN CLINIC CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOOT AND ANKLE PAIN CLINIC CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285015578
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/23/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10401 GREAT EGRET DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORLAND PARK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60467-8581
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-206-0777
Provider Business Mailing Address Fax Number:
708-206-0702

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3313 45TH ST
Provider Second Line Business Practice Location Address:
STE M
Provider Business Practice Location Address City Name:
HIGHLAND
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46322-3294
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-924-1042
Provider Business Practice Location Address Fax Number:
219-924-7989
Provider Enumeration Date:
06/12/2015

Additional Information

Authorized Official

Authorized Official Last Name:
PATEL
Authorized Official First Name:
VIPUL
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
219-659-9000

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  07000921A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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