Provider Demographics
NPI:1598941445
Name:FOOT HEALTH CENTER
Entity Type:Organization
Organization Name:FOOT HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:T
Authorized Official - Last Name:SERLETIC
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:815-933-1633
Mailing Address - Street 1:435 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-1918
Mailing Address - Country:US
Mailing Address - Phone:815-933-1633
Mailing Address - Fax:815-933-1728
Practice Address - Street 1:435 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-1918
Practice Address - Country:US
Practice Address - Phone:815-933-1633
Practice Address - Fax:815-933-1728
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-10
Last Update Date:2008-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL756281Medicare PIN
IL0968900001Medicare NSC