Provider Demographics
NPI:1467622571
Name:FOOT AND ANKLE MED/SURG
Entity Type:Organization
Organization Name:FOOT AND ANKLE MED/SURG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:CORTESE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:309-452-7112
Mailing Address - Street 1:1607 VISA DR STE 2A
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-6160
Mailing Address - Country:US
Mailing Address - Phone:309-452-7112
Mailing Address - Fax:
Practice Address - Street 1:1607 VISA DR STE 2A
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-6160
Practice Address - Country:US
Practice Address - Phone:309-452-7112
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-04
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK06820Medicare PIN
ILK06821Medicare PIN
ILK06826Medicare PIN