Provider Demographics
NPI:1174192801
Name:PODIATRY AT HOME, LLC
Entity Type:Organization
Organization Name:PODIATRY AT HOME, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:EVE
Authorized Official - Last Name:GILLIO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:563-362-8170
Mailing Address - Street 1:5656 JUDGE RD
Mailing Address - Street 2:
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-1211
Mailing Address - Country:US
Mailing Address - Phone:563-362-8170
Mailing Address - Fax:872-333-9156
Practice Address - Street 1:5656 JUDGE RD
Practice Address - Street 2:
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722-1211
Practice Address - Country:US
Practice Address - Phone:563-362-8170
Practice Address - Fax:872-333-9156
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PODIATRY AT HOME, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-06-17
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016005330Medicaid
IA1134338809Medicaid