Provider Demographics
NPI:1437138088
Name:BAXAMUSA, RAHIL (DPM)
Entity Type:Individual
Prefix:DR
First Name:RAHIL
Middle Name:
Last Name:BAXAMUSA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 E CONGRESS PKWY STE B
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-6247
Mailing Address - Country:US
Mailing Address - Phone:815-455-3788
Mailing Address - Fax:815-455-4657
Practice Address - Street 1:411 E CONGRESS PKWY STE B
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014
Practice Address - Country:US
Practice Address - Phone:815-455-3788
Practice Address - Fax:815-455-4657
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-12
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016005238213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL212035Medicare PIN
ILV-05928Medicare UPIN