Provider Demographics
NPI:1831294735
Name:KEVIN M MASSARD LTD PC
Entity Type:Organization
Organization Name:KEVIN M MASSARD LTD PC
Other - Org Name:MASSARD FOOT AND ANKLE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:M
Authorized Official - Last Name:MASSARD
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:630-213-3830
Mailing Address - Street 1:321 W RAILROAD AVE
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:IL
Mailing Address - Zip Code:60103-4428
Mailing Address - Country:US
Mailing Address - Phone:630-213-3830
Mailing Address - Fax:630-213-3895
Practice Address - Street 1:321 W RAILROAD AVE
Practice Address - Street 2:
Practice Address - City:BARTLETT
Practice Address - State:IL
Practice Address - Zip Code:60103-4428
Practice Address - Country:US
Practice Address - Phone:630-213-3830
Practice Address - Fax:630-213-3895
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004988213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU82775Medicare UPIN
IL4263700001Medicare NSC
IL997260Medicare PIN