Provider Demographics
NPI:1326228149
Name:PODIATRY MEDICAL SURGICAL CENTER
Entity Type:Organization
Organization Name:PODIATRY MEDICAL SURGICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:YOUNG
Authorized Official - Last Name:LATHROP
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:217-234-3234
Mailing Address - Street 1:821 CHARLESTON AVE
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-4202
Mailing Address - Country:US
Mailing Address - Phone:217-234-3234
Mailing Address - Fax:217-234-4323
Practice Address - Street 1:821 CHARLESTON AVE
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-4202
Practice Address - Country:US
Practice Address - Phone:217-234-3234
Practice Address - Fax:217-234-4323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-08
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL226290Medicare PIN