=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184339376
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FOOTSTEPS OF ILLINOIS, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2023
-----------------------------------------------------
Last Update Date | 02/12/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6999 REDANSA DR STE 5A
-----------------------------------------------------
City | ROCKFORD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61108-1201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-229-1008
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6999 REDANSA DR STE 5A
-----------------------------------------------------
City | ROCKFORD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61108-1201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-229-1008
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/AUTHORIZED OFFICIAL
-----------------------------------------------------
Name | ZUBAIR KHAN
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 815-229-1008
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213EP1101X
-----------------------------------------------------
Taxonomy Name | Primary Podiatric Medicine Podiatrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------