Provider Demographics
NPI:1033233739
Name:FOOT AND ANKLE ASSOCIATES OF CENTRAL ILLINOIS LLC
Entity Type:Organization
Organization Name:FOOT AND ANKLE ASSOCIATES OF CENTRAL ILLINOIS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:FLEISCHLI
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:217-243-1101
Mailing Address - Street 1:1515 W WALNUT ST STE 12
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62650-1158
Mailing Address - Country:US
Mailing Address - Phone:217-243-1101
Mailing Address - Fax:217-243-5003
Practice Address - Street 1:100 W 15TH ST
Practice Address - Street 2:
Practice Address - City:BEARDSTOWN
Practice Address - State:IL
Practice Address - Zip Code:62618-1774
Practice Address - Country:US
Practice Address - Phone:217-323-2707
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004737332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILDA1788OtherGROUP RAILROAD MEDICARE #
IL06932011OtherBCBS
IL205953Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
ILDA1788OtherGROUP RAILROAD MEDICARE #