Provider Demographics
NPI:1639391907
Name:KIRK M BOTT DBA LOGAN AVENUE FOOT CLINIC
Entity type:Organization
Organization Name:KIRK M BOTT DBA LOGAN AVENUE FOOT CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIRK
Authorized Official - Middle Name:M
Authorized Official - Last Name:BOTT
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:217-442-4186
Mailing Address - Street 1:612 N LOGAN AVENUE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61832
Mailing Address - Country:US
Mailing Address - Phone:217-442-4186
Mailing Address - Fax:
Practice Address - Street 1:612 N LOGAN AVENUE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832
Practice Address - Country:US
Practice Address - Phone:217-442-4186
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016003907213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1376655019OtherINDIVIDUAL NPI #
4449930001OtherDMERC
CE0883OtherRAILROAD MEDICARE GROUP
IL1649379504OtherINDIVIDUAL NPI #
480010681OtherRAILROAD MEDICARE INDIVID
P00380788OtherRAILROAD MEDICARE INDIVID
IL961650Medicare ID - Type UnspecifiedLOGAN FOOT CLINIC GROUP #
P00380788OtherRAILROAD MEDICARE INDIVID
4449930001OtherDMERC
ILT83356Medicare UPIN
CE0883OtherRAILROAD MEDICARE GROUP