Provider Demographics
NPI:1073817805
Name:SUBURBAN PODIATRY ASSOCIATES, P.C.
Entity Type:Organization
Organization Name:SUBURBAN PODIATRY ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:JANSYN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:630-893-3668
Mailing Address - Street 1:303 E ARMY TRAIL RD
Mailing Address - Street 2:SUITE #101
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60108-2169
Mailing Address - Country:US
Mailing Address - Phone:630-893-3668
Mailing Address - Fax:630-893-3670
Practice Address - Street 1:303 E ARMY TRAIL RD
Practice Address - Street 2:SUITE #101
Practice Address - City:BLOOMINGDALE
Practice Address - State:IL
Practice Address - Zip Code:60108-2169
Practice Address - Country:US
Practice Address - Phone:630-893-3668
Practice Address - Fax:630-893-3670
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-09
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016-003968213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL763840Medicare PIN
IL4605900001Medicare NSC
ILT38731Medicare UPIN