1922230093 NPI number — ADVANCED FOOT AND ANKLE SURGEONS INC

Table of content: (NPI 1922230093)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922230093 NPI number — ADVANCED FOOT AND ANKLE SURGEONS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED FOOT AND ANKLE SURGEONS 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:
1922230093
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/08/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2180 OAKLAND DR
Provider Second Line Business Mailing Address:
UNIT A
Provider Business Mailing Address City Name:
SYCAMORE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60178-3122
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-669-4811
Provider Business Mailing Address Fax Number:
815-986-6062

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2180 OAKLAND DR
Provider Second Line Business Practice Location Address:
UNIT A
Provider Business Practice Location Address City Name:
SYCAMORE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60178-3122
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-669-4811
Provider Business Practice Location Address Fax Number:
815-986-6062
Provider Enumeration Date:
08/21/2009

Additional Information

Authorized Official

Authorized Official Last Name:
PACACCIO
Authorized Official First Name:
DOUGLAS
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
630-352-3700

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  016005351 , 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: 1013113265 . This is a "INDIVIDUAL NPI" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 016005347 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1013005867 . This is a "INDIVIDUAL NPI" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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