Provider Demographics
NPI:1518969344
Name:EVANSTON PODIATRIC SURGEONS PC
Entity Type:Organization
Organization Name:EVANSTON PODIATRIC SURGEONS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TAYEB
Authorized Official - Middle Name:S
Authorized Official - Last Name:HUSSAIN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:847-475-9030
Mailing Address - Street 1:2500 RIDGE AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-2455
Mailing Address - Country:US
Mailing Address - Phone:847-475-9030
Mailing Address - Fax:847-475-9031
Practice Address - Street 1:2500 RIDGE AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-2455
Practice Address - Country:US
Practice Address - Phone:847-475-9030
Practice Address - Fax:847-475-9031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-11
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004816213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016004816Medicaid
IL571550Medicare PIN
IL5105430001Medicare NSC