=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215963194
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GEORGE J CARIOSCIA DPM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/23/2006
-----------------------------------------------------
Last Update Date | 01/23/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 117 W LAKE ST
-----------------------------------------------------
City | BLOOMINGDALE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60108-1006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-582-3338
-----------------------------------------------------
Fax | 630-582-3316
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 117 W. LAKE STREET
-----------------------------------------------------
City | BLOOMINGDALE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-582-3338
-----------------------------------------------------
Fax | 630-582-3316
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | 016-004560
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------