Provider Demographics
NPI:1770027930
Name:PRO PODIATRY, LLC
Entity Type:Organization
Organization Name:PRO PODIATRY, LLC
Other - Org Name:PREMIER PODIATRY
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:OCONNOR
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:309-807-0384
Mailing Address - Street 1:1512 W REYNOLDS ST STE A
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:IL
Mailing Address - Zip Code:61764-9788
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2501 E COLLEGE AVE STE C
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-2484
Practice Address - Country:US
Practice Address - Phone:309-807-0384
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-07
Last Update Date:2022-09-01
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
IL4811350001Medicare NSC
ILK00030Medicare PIN
ILU70573Medicare UPIN