Provider Demographics
NPI:1770681330
Name:REGIONAL FOOT CENTER LTD
Entity Type:Organization
Organization Name:REGIONAL FOOT CENTER LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PODIATRIST
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:KILLOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:217-348-3339
Mailing Address - Street 1:1301 DEERPATH ROAD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:IL
Mailing Address - Zip Code:61920-8734
Mailing Address - Country:US
Mailing Address - Phone:217-348-3339
Mailing Address - Fax:217-348-3340
Practice Address - Street 1:1301 DEERPATH ROAD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:IL
Practice Address - Zip Code:61920-8734
Practice Address - Country:US
Practice Address - Phone:217-348-3339
Practice Address - Fax:217-348-3340
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2009-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL16005103261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL8958903OtherCIGNA
ILP00082665OtherPALMETTO
IL015-32005OtherBLUE CROSS BLUE SHIELD
IL016005103Medicaid
IL5630810001Medicare NSC
IL203857Medicare ID - Type Unspecified
ILP00082665OtherPALMETTO