Healthcare Provider Details

I. General information

NPI: 1083612683
Provider Name (Legal Business Name): ANTHONY HENRY BORRELLI DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2005
Last Update Date: 12/29/2021
Certification Date: 12/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1660 FEEHANVILLE DR STE 100
MOUNT PROSPECT IL
60056-6019
US

IV. Provider business mailing address

1660 FEEHANVILLE DR STE 450
MT PROSPECT IL
60056-6023
US

V. Phone/Fax

Practice location:
  • Phone: 847-390-7666
  • Fax: 847-390-9345
Mailing address:
  • Phone: 847-390-7666
  • Fax: 847-390-9345

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number016-003340
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number016-003340
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: