Provider Demographics
NPI:1639344781
Name:BRIAN A. KING
Entity Type:Organization
Organization Name:BRIAN A. KING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-848-0021
Mailing Address - Street 1:6142 W ROOSEVELT ROAD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60304
Mailing Address - Country:US
Mailing Address - Phone:708-848-0021
Mailing Address - Fax:708-848-0598
Practice Address - Street 1:6142 ROOSEVELT RD
Practice Address - Street 2:SUITE 105
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60304-2311
Practice Address - Country:US
Practice Address - Phone:708-848-0021
Practice Address - Fax:708-848-0598
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-29
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016004091Medicaid
788870Medicare PIN
IL016004091Medicaid
0681200001Medicare NSC