Provider Demographics
NPI:1023231693
Name:MIDWEST FOOT AND ANKLE SPECIALISTS PC
Entity type:Organization
Organization Name:MIDWEST FOOT AND ANKLE SPECIALISTS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:FREEL
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:217-223-3668
Mailing Address - Street 1:3740 E LAKE CTR
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62305-5805
Mailing Address - Country:US
Mailing Address - Phone:217-223-3668
Mailing Address - Fax:217-223-3412
Practice Address - Street 1:3740 E LAKE CTR
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62305-5805
Practice Address - Country:US
Practice Address - Phone:217-223-3668
Practice Address - Fax:217-223-3412
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL060228083213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL132005OtherBLUE CROSS BLUE SHIELD
IL4544460003Medicare NSC
MO4544460002Medicare NSC
IL132005OtherBLUE CROSS BLUE SHIELD
IL4544460001Medicare NSC
MO990001775Medicare PIN