Healthcare Provider Details

I. General information

NPI: 1992959571
Provider Name (Legal Business Name): BLOOMINGDALE FOOT & ANKLE ASSOCIATES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2008
Last Update Date: 08/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 FAIRFIELD WAY STE 110
BLOOMINGDALE IL
60108-1557
US

IV. Provider business mailing address

129 FAIRFIELD WAY STE 110
BLOOMINGDALE IL
60108-1557
US

V. Phone/Fax

Practice location:
  • Phone: 630-894-3000
  • Fax: 630-894-3050
Mailing address:
  • Phone: 630-894-3000
  • Fax: 630-894-3050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number016003453
License Number StateIL

VIII. Authorized Official

Name: TINA BOMBARD
Title or Position: BILLING MANAGER
Credential:
Phone: 630-897-6851