Provider Demographics
NPI:1912930793
Name:FOOT HEALTH CENTER INC P C
Entity Type:Organization
Organization Name:FOOT HEALTH CENTER INC P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GINA
Authorized Official - Middle Name:M
Authorized Official - Last Name:REAGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-344-4449
Mailing Address - Street 1:PO BOX 340
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-0340
Mailing Address - Country:US
Mailing Address - Phone:618-344-4449
Mailing Address - Fax:618-344-4551
Practice Address - Street 1:122 E ZUPAN ST
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-2010
Practice Address - Country:US
Practice Address - Phone:618-344-4449
Practice Address - Fax:618-344-4551
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2009-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL060-004872213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL060101285OtherBC/BS GROUP#
ILCB0674OtherRAILROAD MEDICARE GROUP#
IL060101285OtherBC/BS GROUP#
MO000011510Medicare PIN
ILCB0674OtherRAILROAD MEDICARE GROUP#