Provider Demographics
NPI:1841311669
Name:PODIATRY MEDICAL SURGICAL CENTER
Entity type:Organization
Organization Name:PODIATRY MEDICAL SURGICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MRS
Authorized Official - First Name:BECKY
Authorized Official - Middle Name:C
Authorized Official - Last Name:LATHROP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-544-7312
Mailing Address - Street 1:1106 N ALLEN ST
Mailing Address - Street 2:
Mailing Address - City:ROBINSON
Mailing Address - State:IL
Mailing Address - Zip Code:62454-1116
Mailing Address - Country:US
Mailing Address - Phone:618-544-7312
Mailing Address - Fax:618-544-7600
Practice Address - Street 1:1106 N ALLEN ST
Practice Address - Street 2:
Practice Address - City:ROBINSON
Practice Address - State:IL
Practice Address - Zip Code:62454-1116
Practice Address - Country:US
Practice Address - Phone:618-544-7312
Practice Address - Fax:618-544-7600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0290550001Medicare NSC
IL211712Medicare ID - Type UnspecifiedPROVIDER ID NUMBER