1790783736 NPI number — MERCADO FOOT AND ANKLE CLINICS SOUTH

Table of content: (NPI 1790783736)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790783736 NPI number — MERCADO FOOT AND ANKLE CLINICS SOUTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MERCADO FOOT AND ANKLE CLINICS SOUTH
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:
1790783736
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/28/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3245 GROVE AVE
Provider Second Line Business Mailing Address:
SUITE 106
Provider Business Mailing Address City Name:
BERWYN
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60402-3474
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3245 GROVE AVE
Provider Second Line Business Practice Location Address:
SUITE 106
Provider Business Practice Location Address City Name:
BERWYN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60402-3474
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-484-3599
Provider Business Practice Location Address Fax Number:
708-749-0727
Provider Enumeration Date:
07/13/2005

Additional Information

Authorized Official

Authorized Official Last Name:
MERCADO-CIESSAU
Authorized Official First Name:
CYNTHIA
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
PODIATRIST/OWNER
Authorized Official Telephone Number:
708-484-3599

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  016004482 , 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: 016004482 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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