Provider Demographics
NPI:1073948618
Name:DAVISON-MCNEAL SC
Entity Type:Organization
Organization Name:DAVISON-MCNEAL SC
Other - Org Name:DAVISON-MCNEAL SC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIBIBI
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVISON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:773-641-1489
Mailing Address - Street 1:6330 S INGLESIDE AVE
Mailing Address - Street 2:UNIT 1
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60637-3620
Mailing Address - Country:US
Mailing Address - Phone:773-641-1489
Mailing Address - Fax:
Practice Address - Street 1:6330 S INGLESIDE AVE
Practice Address - Street 2:UNIT 1
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637-3620
Practice Address - Country:US
Practice Address - Phone:773-641-1489
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-12
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016005441213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty