Provider Demographics
NPI:1134224199
Name:SOUTHERN ILLINOIS FOOT AND ANKLE CLINIC LTD
Entity type:Organization
Organization Name:SOUTHERN ILLINOIS FOOT AND ANKLE CLINIC LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL BILLER
Authorized Official - Prefix:
Authorized Official - First Name:TAMI
Authorized Official - Middle Name:
Authorized Official - Last Name:HEFNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-457-0431
Mailing Address - Street 1:PO BOX 997
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62903-0997
Mailing Address - Country:US
Mailing Address - Phone:618-457-0431
Mailing Address - Fax:618-457-5199
Practice Address - Street 1:1235 CEDAR CT
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-5335
Practice Address - Country:US
Practice Address - Phone:618-457-0431
Practice Address - Fax:618-457-5199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016003389213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016003389Medicaid
IL016005370Medicaid
IL016004187Medicaid
IL1013941392OtherRAILROAD MEDICARE
IL1972533933OtherRAILROAD MEDICARE
ILCI5845OtherRAILROAD MEDICARE
ILU42069Medicare UPIN
IL1972533933OtherRAILROAD MEDICARE
IL0718600001Medicare NSC
IL505620Medicare PIN
ILU91437Medicare UPIN
ILCI5845OtherRAILROAD MEDICARE
ILL66907Medicare PIN