Provider Demographics
NPI:1265430730
Name:MERCADO FOOT AND ANKLE CLINICS
Entity type:Organization
Organization Name:MERCADO FOOT AND ANKLE CLINICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST/OWNER/PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:708-748-3337
Mailing Address - Street 1:4143 SAUK TRL
Mailing Address - Street 2:
Mailing Address - City:RICHTON PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60471-1253
Mailing Address - Country:US
Mailing Address - Phone:708-748-3337
Mailing Address - Fax:708-747-3338
Practice Address - Street 1:4143 SAUK TRL
Practice Address - Street 2:
Practice Address - City:RICHTON PARK
Practice Address - State:IL
Practice Address - Zip Code:60471-1253
Practice Address - Country:US
Practice Address - Phone:708-748-3337
Practice Address - Fax:708-747-3338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-08
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1634248OtherBCBS
705352LOtherAETNA
P00145458OtherGBA RAILROAD
P00145458OtherGBA RAILROAD
208981Medicare ID - Type Unspecified
IL5181390001Medicare NSC