Provider Demographics
NPI:1902180201
Name:FREEDOM FOOT CLINICS OF ILLINOIS SC
Entity Type:Organization
Organization Name:FREEDOM FOOT CLINICS OF ILLINOIS SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MERCADO
Authorized Official - Suffix:I
Authorized Official - Credentials:DPM
Authorized Official - Phone:708-484-3599
Mailing Address - Street 1:3245 GROVE AVE
Mailing Address - Street 2:SUITE #103
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-3474
Mailing Address - Country:US
Mailing Address - Phone:708-484-3599
Mailing Address - Fax:708-749-0727
Practice Address - Street 1:3245 GROVE AVE
Practice Address - Street 2:SUITE #103
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:2011-10-05
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004482213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016004482Medicaid
IL016004482Medicaid
ILU17344Medicare UPIN