Provider Demographics
NPI:1033381025
Name:DANIEL L SYVERSON DPM
Entity Type:Organization
Organization Name:DANIEL L SYVERSON DPM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:SYVERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:815-389-8088
Mailing Address - Street 1:PO BOX 311
Mailing Address - Street 2:
Mailing Address - City:ROSCOE
Mailing Address - State:IL
Mailing Address - Zip Code:61073-0311
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12360 DUNHAM DR
Practice Address - Street 2:
Practice Address - City:ROSCOE
Practice Address - State:IL
Practice Address - Zip Code:61073-9096
Practice Address - Country:US
Practice Address - Phone:815-389-8088
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-31
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL01600404332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016004040Medicaid
IL016004040Medicaid
T38617Medicare UPIN
0904580001Medicare NSC