Healthcare Provider Details

I. General information

NPI: 1386854610
Provider Name (Legal Business Name): FOOT AND ANKLE SPECIALISTS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 11/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24039 W LOCKPORT ST
PLAINFIELD IL
60544-1652
US

IV. Provider business mailing address

24039 W LOCKPORT ST
PLAINFIELD IL
60544-1652
US

V. Phone/Fax

Practice location:
  • Phone: 815-254-3338
  • Fax: 815-436-8367
Mailing address:
  • Phone: 815-254-3338
  • Fax: 815-436-8367

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number016004798
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier009908116
Identifier TypeOTHER
Identifier StateIL
Identifier IssuerBCBS PROVIDER LEGACY ID
# 2
Identifier480023719
Identifier TypeOTHER
Identifier StateIL
Identifier IssuerRAILROAD MEDICARE

VIII. Authorized Official

Name: DR. PRAVEEN VOHRA
Title or Position: DPM
Credential: DPM
Phone: 815-254-3338