Provider Demographics
NPI:1174663983
Name:OLYMPIA FOOT & ANKLE CARE, LTD.
Entity Type:Organization
Organization Name:OLYMPIA FOOT & ANKLE CARE, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:O'CONNOR
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:708-799-2900
Mailing Address - Street 1:3347 VOLLMER RD
Mailing Address - Street 2:
Mailing Address - City:FLOSSMOOR
Mailing Address - State:IL
Mailing Address - Zip Code:60422-2003
Mailing Address - Country:US
Mailing Address - Phone:708-799-2900
Mailing Address - Fax:708-799-2919
Practice Address - Street 1:3347 VOLLMER RD
Practice Address - Street 2:
Practice Address - City:FLOSSMOOR
Practice Address - State:IL
Practice Address - Zip Code:60422-2003
Practice Address - Country:US
Practice Address - Phone:708-799-2900
Practice Address - Fax:708-799-2919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2010-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016003696213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK24940Medicare UPIN
IL5678600001Medicare NSC
IL212969Medicare PIN