Provider Demographics
NPI:1619374584
Name:MIDWEST FOOT & ANKLE SPECIALISTS
Entity Type:Organization
Organization Name:MIDWEST FOOT & ANKLE SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:R
Authorized Official - Last Name:RANDALL
Authorized Official - Suffix:JR
Authorized Official - Credentials:DPM
Authorized Official - Phone:866-335-1091
Mailing Address - Street 1:7940 FARMHOUSE RD
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:60423-6810
Mailing Address - Country:US
Mailing Address - Phone:866-335-1091
Mailing Address - Fax:866-335-1091
Practice Address - Street 1:3915 W CAPITOL DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53216-2528
Practice Address - Country:US
Practice Address - Phone:866-335-1091
Practice Address - Fax:866-335-1091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-20
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI858-25213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty