Provider Demographics
NPI:1760437602
Name:MCLEAN FOOT CLINIC,P.C.
Entity Type:Organization
Organization Name:MCLEAN FOOT CLINIC,P.C.
Other - Org Name:HARVARD FOOT CLINIC,P.C.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:IRSHAD
Authorized Official - Middle Name:AHMED
Authorized Official - Last Name:SIDDIQUE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:815-943-7709
Mailing Address - Street 1:400 N DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:HARVARD
Mailing Address - State:IL
Mailing Address - Zip Code:60033-3061
Mailing Address - Country:US
Mailing Address - Phone:815-943-7709
Mailing Address - Fax:847-931-7726
Practice Address - Street 1:400 N DIVISION ST
Practice Address - Street 2:
Practice Address - City:HARVARD
Practice Address - State:IL
Practice Address - Zip Code:60033-3061
Practice Address - Country:US
Practice Address - Phone:815-943-7709
Practice Address - Fax:847-931-7726
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-22
Last Update Date:2007-12-08
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
IL0005632037,004454016OtherBLUECROSS BLUESHIELD
ILT91704Medicare UPIN
IL0005632037,004454016OtherBLUECROSS BLUESHIELD
IL213588Medicare PIN