Healthcare Provider Details

I. General information

NPI: 1902970940
Provider Name (Legal Business Name): ANUSAK SERIRUK DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 11/18/2025
Certification Date: 11/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6560 W HIGGINS AVE
CHICAGO IL
60656-2161
US

IV. Provider business mailing address

6560 W HIGGINS AVE
CHICAGO IL
60656-2161
US

V. Phone/Fax

Practice location:
  • Phone: 773-775-0300
  • Fax:
Mailing address:
  • Phone: 773-775-0300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number016-004765
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: