Provider Demographics
NPI:1205939428
Name:SCROGGINS, ANTHONY (DPM)
Entity type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:
Last Name:SCROGGINS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 W WALNUT ST
Mailing Address - Street 2:SUITE 3B
Mailing Address - City:JACKSONVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62650-1150
Mailing Address - Country:US
Mailing Address - Phone:217-245-4610
Mailing Address - Fax:217-479-0169
Practice Address - Street 1:1515 W WALNUT ST
Practice Address - Street 2:SUITE 3B
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-1150
Practice Address - Country:US
Practice Address - Phone:217-245-4610
Practice Address - Fax:217-479-0169
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2009-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004976213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL8415027OtherBLUE CROSS BLUE SHIELD
IL6186610001Medicare NSC
ILU81887Medicare UPIN
IL205038Medicare PIN
IL8415027OtherBLUE CROSS BLUE SHIELD