1487630406 NPI number — LIBERTYVILLE ANKLE & FOOT CLINIC, INC

Table of content: (NPI 1487630406)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487630406 NPI number — LIBERTYVILLE ANKLE & FOOT CLINIC, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIBERTYVILLE ANKLE & FOOT CLINIC, INC
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:
1487630406
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/25/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1017 W PARK AVE
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
LIBERTYVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60048-2502
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-362-1320
Provider Business Mailing Address Fax Number:
847-362-1823

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1017 W PARK AVE
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
LIBERTYVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60048-2502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-362-1320
Provider Business Practice Location Address Fax Number:
847-362-1823
Provider Enumeration Date:
12/21/2005

Additional Information

Authorized Official

Authorized Official Last Name:
JACOBSEN
Authorized Official First Name:
SCOTT
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
847-362-1320

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  016-005031 , 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: 016005031 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00347050 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 04932511 . This is a "BLUECROSS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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