Healthcare Provider Details

I. General information

NPI: 1811183502
Provider Name (Legal Business Name): SUBURBAN FOOT AND ANKLE SPECIALISTS P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2007
Last Update Date: 09/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 N FARNSWORTH AVE
AURORA IL
60505-3004
US

IV. Provider business mailing address

PO BOX 444
LAKE FOREST IL
60045-0444
US

V. Phone/Fax

Practice location:
  • Phone: 630-898-0022
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number
License Number StateIL

VIII. Authorized Official

Name: LEWIS WASSERMAN
Title or Position: PRESIDENT
Credential:
Phone: 847-219-0539