Provider Demographics
NPI:1467606152
Name:PROFESSIONAL FOOT & ANKLE LLC
Entity Type:Organization
Organization Name:PROFESSIONAL FOOT & ANKLE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:R
Authorized Official - Last Name:RANDALL
Authorized Official - Suffix:JR
Authorized Official - Credentials:DPM
Authorized Official - Phone:866-335-1091
Mailing Address - Street 1:20303 CRAWFORD AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:OLYMPIA FIELDS
Mailing Address - State:IL
Mailing Address - Zip Code:60461-1041
Mailing Address - Country:US
Mailing Address - Phone:708-898-2380
Mailing Address - Fax:708-898-2326
Practice Address - Street 1:20303 CRAWFORD AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:OLYMPIA FIELDS
Practice Address - State:IL
Practice Address - Zip Code:60461-1041
Practice Address - Country:US
Practice Address - Phone:708-898-2380
Practice Address - Fax:708-898-2326
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-08
Last Update Date:2021-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016005113213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4632153OtherBLUE CROSS BLUE SHIELD
ILIL2599Medicare PIN
IL6336630001Medicare NSC
ILIL1517Medicare PIN