Provider Demographics
NPI:1124215876
Name:GITERSONKE FOOT CLINIC, PC
Entity Type:Organization
Organization Name:GITERSONKE FOOT CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PEGGY
Authorized Official - Middle Name:DOLORES
Authorized Official - Last Name:GITERSONKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-931-3338
Mailing Address - Street 1:2412 CORPORATE CTR
Mailing Address - Street 2:
Mailing Address - City:GRANITE CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62040-4192
Mailing Address - Country:US
Mailing Address - Phone:618-931-3338
Mailing Address - Fax:618-931-4905
Practice Address - Street 1:2412 CORPORATE CTR
Practice Address - Street 2:
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040-4192
Practice Address - Country:US
Practice Address - Phone:618-931-3338
Practice Address - Fax:618-931-4905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-26
Last Update Date:2008-01-11
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
IL0394750001Medicare NSC
IL732671Medicare PIN
ILT38313Medicare UPIN
ILCL7908Medicare PIN