Provider Demographics
NPI:1730498627
Name:WILLOW FALLS PODIATRY
Entity Type:Organization
Organization Name:WILLOW FALLS PODIATRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:603-390-9810
Mailing Address - Street 1:1560 SUNCREST LN
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60490-3278
Mailing Address - Country:US
Mailing Address - Phone:815-838-0282
Mailing Address - Fax:815-230-0036
Practice Address - Street 1:16151 WEBER RD
Practice Address - Street 2:SUITE 107
Practice Address - City:CREST HILL
Practice Address - State:IL
Practice Address - Zip Code:60403-0863
Practice Address - Country:US
Practice Address - Phone:815-838-0282
Practice Address - Fax:815-230-0036
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-27
Last Update Date:2010-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016003971213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0060001542OtherBLUE CROSS BLUE SHIELD
IL016003971Medicaid