Provider Demographics
NPI:1609064369
Name:PRO PODIATRY, LLC
Entity Type:Organization
Organization Name:PRO PODIATRY, LLC
Other - Org Name:CENTRAL ILLINOIS FOOT & ANKLE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:O'CONNOR
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:815-842-6551
Mailing Address - Street 1:1512 W REYNOLDS ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:PONTIAC
Mailing Address - State:IL
Mailing Address - Zip Code:61764-9781
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1512 W REYNOLDS ST
Practice Address - Street 2:SUITE A
Practice Address - City:PONTIAC
Practice Address - State:IL
Practice Address - Zip Code:61764-9781
Practice Address - Country:US
Practice Address - Phone:815-842-6551
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-09
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016005106213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK00030OtherMEDICARE INDIVIDUAL
ILU70573Medicare UPIN
IL4811350001Medicare NSC
IL206264Medicare PIN