Healthcare Provider Details

I. General information

NPI: 1942371265
Provider Name (Legal Business Name): NORTHWEST FOOT AND ANKLE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2006
Last Update Date: 06/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4701 N CUMBERLAND AVE SUITE 19
NORRIDGE IL
60706-2905
US

IV. Provider business mailing address

4701 N CUMBERLAND AVE SUITE 19
NORRIDGE IL
60706-2905
US

V. Phone/Fax

Practice location:
  • Phone: 708-456-5150
  • Fax:
Mailing address:
  • Phone: 708-456-5150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number016004936
License Number StateIL

VIII. Authorized Official

Name: DR. ROBERT ANGLIM
Title or Position: PRESIDENT
Credential: DPM
Phone: 708-456-5150