Provider Demographics
NPI:1124206834
Name:DUPAGE FOOT & ANKLE ASSOCIATES
Entity Type:Organization
Organization Name:DUPAGE FOOT & ANKLE ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RUDOLPH
Authorized Official - Middle Name:J
Authorized Official - Last Name:PETRICH
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:630-766-8720
Mailing Address - Street 1:14 S ADDISON ST
Mailing Address - Street 2:
Mailing Address - City:BENSENVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60106-2126
Mailing Address - Country:US
Mailing Address - Phone:630-766-8720
Mailing Address - Fax:630-766-9228
Practice Address - Street 1:14 S ADDISON ST
Practice Address - Street 2:
Practice Address - City:BENSENVILLE
Practice Address - State:IL
Practice Address - Zip Code:60106-2126
Practice Address - Country:US
Practice Address - Phone:630-766-8720
Practice Address - Fax:630-766-9228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-05
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016003067213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5464030001Medicare NSC