Provider Demographics
NPI:1144438011
Name:ST. CHARLES PODIATRY ASSOC
Entity type:Organization
Organization Name:ST. CHARLES PODIATRY ASSOC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERNEST
Authorized Official - Middle Name:V
Authorized Official - Last Name:ISADORE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:630-377-5001
Mailing Address - Street 1:2210 DEAN ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60175-1066
Mailing Address - Country:US
Mailing Address - Phone:630-377-5001
Mailing Address - Fax:630-377-5021
Practice Address - Street 1:2210 DEAN ST
Practice Address - Street 2:SUITE C
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60175-1066
Practice Address - Country:US
Practice Address - Phone:630-377-5001
Practice Address - Fax:630-377-5021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016002699213ES0103X
IL016002685213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
307570OtherMEDICARE ID
IL004515235OtherBCBS PROV#
IL004515235OtherBCBS PROV#
IL307571Medicare PIN
307570OtherMEDICARE ID