Provider Demographics
NPI:1790783736
Name:MERCADO FOOT AND ANKLE CLINICS SOUTH
Entity Type:Organization
Organization Name:MERCADO FOOT AND ANKLE CLINICS SOUTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:M
Authorized Official - Last Name:MERCADO-CIESSAU
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:708-484-3599
Mailing Address - Street 1:3245 GROVE AVE
Mailing Address - Street 2:SUITE 106
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-3474
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3245 GROVE AVE
Practice Address - Street 2:SUITE 106
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-3474
Practice Address - Country:US
Practice Address - Phone:708-484-3599
Practice Address - Fax:708-749-0727
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-13
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004482213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016004482Medicaid
209721Medicare ID - Type Unspecified
IL016004482Medicaid