Provider Demographics
NPI: | 1528205168 |
---|---|
Name: | ASSOCIATED FOOT SURGEONS OF JOLIET LTD |
Entity Type: | Organization |
Organization Name: | ASSOCIATED FOOT SURGEONS OF JOLIET LTD |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OWNER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | ANTHONY |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | EASLEY |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | DPM |
Authorized Official - Phone: | 815-725-5211 |
Mailing Address - Street 1: | 2204 WEBER ROAD |
Mailing Address - Street 2: | |
Mailing Address - City: | CREST HILL |
Mailing Address - State: | IL |
Mailing Address - Zip Code: | 60403 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 815-725-5211 |
Mailing Address - Fax: | 815-725-4816 |
Practice Address - Street 1: | 2204 WEBER ROAD |
Practice Address - Street 2: | |
Practice Address - City: | CREST HILL |
Practice Address - State: | IL |
Practice Address - Zip Code: | 60403 |
Practice Address - Country: | US |
Practice Address - Phone: | 815-725-5211 |
Practice Address - Fax: | 815-725-4816 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2009-01-20 |
Last Update Date: | 2009-01-20 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
IL | 016-003985 | 261QP1100X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 261QP1100X | Ambulatory Health Care Facilities | Clinic/Center | Podiatric |