Provider Demographics
NPI:1528394343
Name:ADVANCED FOOT AND ANKLE SURGEONS, INC.
Entity Type:Organization
Organization Name:ADVANCED FOOT AND ANKLE SURGEONS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:PACACCIO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:630-352-3700
Mailing Address - Street 1:2180 OAKLAND DR
Mailing Address - Street 2:UNIT A
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-3122
Mailing Address - Country:US
Mailing Address - Phone:815-669-4811
Mailing Address - Fax:815-986-6062
Practice Address - Street 1:215 HILLCREST AVE
Practice Address - Street 2:SUITE B
Practice Address - City:YORKVILLE
Practice Address - State:IL
Practice Address - Zip Code:60560-1366
Practice Address - Country:US
Practice Address - Phone:630-352-3700
Practice Address - Fax:815-986-6062
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADVANCED FOOT AND ANKLE SURGEONS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-10-29
Last Update Date:2015-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016005351213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016005351Medicaid
IL1013005867OtherINDIVIDUAL NPI
IL1013005867OtherINDIVIDUAL NPI