Provider Demographics
NPI:1043302144
Name:FOOT & ANKLE ASSOCIATES OF CENTRAL ILLINOIS LLC
Entity Type:Organization
Organization Name:FOOT & 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
Mailing Address - Street 2:SUITE 12
Mailing Address - City:JACKSONVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62650-1150
Mailing Address - Country:US
Mailing Address - Phone:217-243-1101
Mailing Address - Fax:217-243-5003
Practice Address - Street 1:1515 W WALNUT ST
Practice Address - Street 2:SUITE 12
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-1150
Practice Address - Country:US
Practice Address - Phone:217-243-1101
Practice Address - Fax:217-243-5003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL06932011OtherBCBS
ILDA1788OtherGROUP RAILROAD MEDICARE #
ILDA1788OtherGROUP RAILROAD MEDICARE #
IL205953Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER