Provider Demographics
NPI:1780707950
Name:ALTON PODIATRY CLINIC, P.C.
Entity type:Organization
Organization Name:ALTON PODIATRY CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:HUELS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:618-462-2316
Mailing Address - Street 1:3535 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-5009
Mailing Address - Country:US
Mailing Address - Phone:618-462-2316
Mailing Address - Fax:618-462-0954
Practice Address - Street 1:3535 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-5009
Practice Address - Country:US
Practice Address - Phone:618-462-2316
Practice Address - Fax:618-462-0954
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2008-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004028213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4814700001Medicare NSC
IL200467Medicare PIN