Provider Demographics
NPI:1558344598
Name:MERTZENICH, EDMOND (DPM)
Entity Type:Individual
Prefix:DR
First Name:EDMOND
Middle Name:
Last Name:MERTZENICH
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:DR
Other - First Name:EDMOND
Other - Middle Name:
Other - Last Name:MERTZENICH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPM
Mailing Address - Street 1:1200 W. STATE ST
Mailing Address - Street 2:CRUSADER COMMUNITY HEALTH
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61102-2112
Mailing Address - Country:US
Mailing Address - Phone:815-490-1600
Mailing Address - Fax:815-490-1485
Practice Address - Street 1:1200 W STATE ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61102-2112
Practice Address - Country:US
Practice Address - Phone:815-490-1600
Practice Address - Fax:815-490-1485
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016003825213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016003825Medicaid
ILT38530Medicare UPIN
IL752491Medicare ID - Type UnspecifiedMEDICARE