Provider Demographics
NPI:1740463678
Name:TINA R. ENTWISTLE, D.P.M., P.C.
Entity type:Organization
Organization Name:TINA R. ENTWISTLE, D.P.M., P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TINA
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:ENTWISTLE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:815-227-0041
Mailing Address - Street 1:6778 MILL RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-2502
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6778 MILL RD
Practice Address - Street 2:SUITE 100
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2502
Practice Address - Country:US
Practice Address - Phone:815-227-0041
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-13
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016-005194213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty