Provider Demographics
NPI:1881823623
Name:FAMILY FOOT AND ANKLE CENTER OF SOUTHERN ILLINOIS LLC
Entity Type:Organization
Organization Name:FAMILY FOOT AND ANKLE CENTER OF SOUTHERN ILLINOIS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIC PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MELINDA
Authorized Official - Middle Name:BETH
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:618-985-3338
Mailing Address - Street 1:PO BOX 508
Mailing Address - Street 2:
Mailing Address - City:CARTERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62918-0508
Mailing Address - Country:US
Mailing Address - Phone:618-985-3338
Mailing Address - Fax:618-985-3339
Practice Address - Street 1:807 S DIVISION ST
Practice Address - Street 2:
Practice Address - City:CARTERVILLE
Practice Address - State:IL
Practice Address - Zip Code:62918-1528
Practice Address - Country:US
Practice Address - Phone:618-985-3338
Practice Address - Fax:618-985-3339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-14
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6299710001Medicare NSC
ILIL2449Medicare PIN