Provider Demographics
NPI:1548216047
Name:MIDSTATE PODIATRY ASSOCIATES LTD
Entity Type:Organization
Organization Name:MIDSTATE PODIATRY ASSOCIATES LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:H
Authorized Official - Middle Name:R
Authorized Official - Last Name:HADDEN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:309-663-2306
Mailing Address - Street 1:2708 MCGRAW DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-6012
Mailing Address - Country:US
Mailing Address - Phone:309-663-2306
Mailing Address - Fax:309-662-1213
Practice Address - Street 1:2708 MCGRAW DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-6012
Practice Address - Country:US
Practice Address - Phone:309-663-2306
Practice Address - Fax:309-662-1213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2012-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL060-000800213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL60115936OtherBLUE SHIELD GROUP NUMBER
IL620650Medicare ID - Type UnspecifiedGROUP PRACTICE NUMBER