Provider Demographics
NPI:1285621235
Name:DISOMMA FOOT & ANKLE CLINIC PC
Entity type:Organization
Organization Name:DISOMMA FOOT & ANKLE CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:M
Authorized Official - Last Name:DISOMMA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:708-383-5554
Mailing Address - Street 1:1100 LAKE ST
Mailing Address - Street 2:STE 248
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60301-1015
Mailing Address - Country:US
Mailing Address - Phone:708-383-5554
Mailing Address - Fax:708-383-9321
Practice Address - Street 1:1100 LAKE ST
Practice Address - Street 2:STE 248
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1015
Practice Address - Country:US
Practice Address - Phone:708-383-5554
Practice Address - Fax:708-383-9321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-04
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004585213E00000X
IL060007223213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016004585Medicaid
IL211489Medicare PIN
U36162Medicare UPIN