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General NPI Number Information
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NPI Number | 1306071972
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Entity Type | Organization
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Legal Business Name | EDGEBROOK FOOT & ANKLE CLINIC, INC
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Dates
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Enumeration Date | 05/26/2009
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Last Update Date | 06/08/2012
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Provider Practice Location Address
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Address Line | 5330 W DEVON AVE SUITE 10
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City | CHICAGO
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State | IL
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Zip | 60646-4148
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Country | US
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Telephone | 773-792-9300
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Fax | 773-792-9302
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Provider Business Mailing Address
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Address Line | 5330 W DEVON AVE SUITE 10
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City | CHICAGO
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State | IL
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Zip | 60646-4148
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Country | US
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Telephone | 773-792-9300
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Fax | 773-792-9302
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Authorized Official
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Title or Position | ADMINSTRATOR
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Name | DR. PRATIBHA B PATEL
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Credential | DPM
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Telephone | 773-792-9300
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213ES0103X
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Taxonomy Name | Foot & Ankle Surgery Podiatrist
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License Number | 016.005386
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License Number State | IL
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