Provider Demographics
NPI:1659393692
Name:ST. CHARLES FOOT AND ANKLE CENTER PC
Entity type:Organization
Organization Name:ST. CHARLES FOOT AND ANKLE CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:BETTAG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-584-4200
Mailing Address - Street 1:2320 DEAN ST STE 104
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60175-1068
Mailing Address - Country:US
Mailing Address - Phone:630-584-4200
Mailing Address - Fax:
Practice Address - Street 1:2320 DEAN ST STE 104
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60175-1068
Practice Address - Country:US
Practice Address - Phone:630-584-4200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2009-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL060007575213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6094960001Medicare NSC
IL572840Medicare ID - Type Unspecified