Healthcare Provider Details

I. General information

NPI: 1609316686
Provider Name (Legal Business Name): KV FOOT AND ANKLE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2017
Last Update Date: 10/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

629 COLUMBINE AVE
LISLE IL
60532-2711
US

IV. Provider business mailing address

629 COLUMBINE AVE
LISLE IL
60532-2711
US

V. Phone/Fax

Practice location:
  • Phone: 708-341-6428
  • Fax:
Mailing address:
  • Phone: 708-341-6428
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number016005612
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number016005612
License Number StateIL

VIII. Authorized Official

Name: DR. SARAH ANN SUMMER MATOUK
Title or Position: PRESIDENT
Credential: DPM
Phone: 708-341-6428