Provider Demographics
NPI:1467867234
Name:PREMIER FOOT AND ANKLE OF ILLINOIS, PC
Entity Type:Organization
Organization Name:PREMIER FOOT AND ANKLE OF ILLINOIS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GABRIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:CARDENAS
Authorized Official - Suffix:JR
Authorized Official - Credentials:DPM
Authorized Official - Phone:618-288-2835
Mailing Address - Street 1:6810 STATE ROUTE 162
Mailing Address - Street 2:SUITE 20
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-8587
Mailing Address - Country:US
Mailing Address - Phone:618-288-2835
Mailing Address - Fax:618-288-6162
Practice Address - Street 1:6810 STATE ROUTE 162
Practice Address - Street 2:SUITE 20
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-8587
Practice Address - Country:US
Practice Address - Phone:618-288-2835
Practice Address - Fax:618-288-6162
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-30
Last Update Date:2016-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016.005608213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF100153987OtherMEDICARE PTAN GROUP
ILF100153987OtherMEDICARE PTAN GROUP