Healthcare Provider Details

I. General information

NPI: 1588175749
Provider Name (Legal Business Name): RAFATI FOOT AND ANKLE CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2017
Last Update Date: 10/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 N LARKIN AVE STE 100
JOLIET IL
60435-3449
US

IV. Provider business mailing address

9340 LOCHWOOD PL
TINLEY PARK IL
60487-4797
US

V. Phone/Fax

Practice location:
  • Phone: 219-688-6292
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number016005230
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number016005230
License Number StateIL

VIII. Authorized Official

Name: MURAD ABDEL-QADER
Title or Position: OWNER
Credential:
Phone: 219-688-6292