Healthcare Provider Details

I. General information

NPI: 1790783736
Provider Name (Legal Business Name): MERCADO FOOT AND ANKLE CLINICS SOUTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2005
Last Update Date: 01/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3245 GROVE AVE SUITE 106
BERWYN IL
60402-3474
US

IV. Provider business mailing address

3245 GROVE AVE SUITE 106
BERWYN IL
60402-3474
US

V. Phone/Fax

Practice location:
  • Phone: 708-484-3599
  • Fax: 708-749-0727
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number016004482
License Number StateIL

VIII. Authorized Official

Name: DR. CYNTHIA M. MERCADO-CIESSAU
Title or Position: PODIATRIST/OWNER
Credential: DPM
Phone: 708-484-3599