Provider Demographics
NPI:1508845884
Name:ILLINOIS CENTER FOR FOOT & ANKLE SURGERY INC
Entity Type:Organization
Organization Name:ILLINOIS CENTER FOR FOOT & ANKLE SURGERY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:F
Authorized Official - Last Name:GRADY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:708-424-3201
Mailing Address - Street 1:4650 SOUTHWEST HWY
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-1836
Mailing Address - Country:US
Mailing Address - Phone:708-424-6353
Mailing Address - Fax:
Practice Address - Street 1:4650 SOUTHWEST HWY
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-1836
Practice Address - Country:US
Practice Address - Phone:708-424-6353
Practice Address - Fax:708-424-7095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-13
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
206947Medicare ID - Type Unspecified