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General NPI Number Information
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NPI Number | 1467606152
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Entity Type | Organization
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Legal Business Name | PROFESSIONAL FOOT & ANKLE LLC
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Dates
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Enumeration Date | 11/08/2008
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Last Update Date | 05/17/2025
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Provider Practice Location Address
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Address Line | 231 MAIN ST
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City | PARK FOREST
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State | IL
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Zip | 60466-2097
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Country | US
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Telephone | 708-749-3338
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Fax | 708-748-4332
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Provider Business Mailing Address
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Address Line | PO BOX 1889
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City | MATTESON
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State | IL
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Zip | 60443-4889
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Country | US
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Telephone | 708-250-0785
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Fax | 708-898-2326
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Authorized Official
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Title or Position | MEMBER
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Name | DR. JEROME R RANDALL JR.
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Credential | DPM
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Telephone | 708-250-0785
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213E00000X
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Taxonomy Name | Podiatrist
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License Number | 016005113
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License Number State | IL
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