Healthcare Provider Details

I. General information

NPI: 1700273190
Provider Name (Legal Business Name): MCLEAN COUNTY FOOT & ANKLE, LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2015
Last Update Date: 01/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 GE RD STE 4
BLOOMINGTON IL
61704
US

IV. Provider business mailing address

3801 GE RD STE 4
BLOOMINGTON IL
61704-4193
US

V. Phone/Fax

Practice location:
  • Phone: 309-662-9001
  • Fax: 309-662-9005
Mailing address:
  • Phone: 309-662-9001
  • Fax: 309-662-9005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number016005369
License Number StateIL

VIII. Authorized Official

Name: GERALD PAUL
Title or Position: CO-OWNER
Credential: DPM
Phone: 309-662-9001