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NPI Code Detail

MEDICARE: SUBURBAN FOOT AND ANKLE SPECIALISTS P.C.

MEDICARE: SUBURBAN FOOT AND ANKLE SPECIALISTS P.C.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1213ES0131XFoot Surgery PodiatristIL

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
10004523326OTHERILBCBS OF ILLINOIS

General Provider Information

NPI Number : 1811183502
Entity Type Code : Organization
Provider Name (Legal Business Name) : SUBURBAN FOOT AND ANKLE SPECIALISTS P.C.
Provider Business Mailing Address
First Line : PO BOX 444
Second Line :
City : LAKE FOREST
State : IL
Zip : 60045-0444
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 475 N FARNSWORTH AVE
Second Line :
City : AURORA
State : IL
Zip : 60505-3004
Country : US
Telephone Number : 630-898-0022
Fax Number :
Authorized Official
Title or Position : PRESIDENT
Name : LEWIS WASSERMAN
Credential :
Telephone Number : 847-219-0539
Provider Enumeration Date : 09/17/2007
Last Update Date : 09/17/2007

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