1447360896 NPI number — MERCADO FOOT & ANKLE CLINIC WEST LLC

Table of content: (NPI 1447360896)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447360896 NPI number — MERCADO FOOT & ANKLE CLINIC WEST LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MERCADO FOOT & ANKLE CLINIC WEST LLC
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:
1447360896
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/23/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
24024 BRANCASTER DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NAPERVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60564-8044
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-922-7722
Provider Business Mailing Address Fax Number:
630-922-7727

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
24024 BRANCASTER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NAPERVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60564-8044
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-922-7722
Provider Business Practice Location Address Fax Number:
630-922-7727
Provider Enumeration Date:
08/30/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MERCADO
Authorized Official First Name:
O. KENT
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
630-922-7722

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  016004238 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 5180850001 . This is a "ADMINASTAR DMERC #" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 016004238 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: CI5229 . This is a "RAILROAD MEDICARE GRP #" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 60001691 . This is a "BC/BS PROVIDER #" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".