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General NPI Number Information
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NPI Number | 1467867234
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Entity Type | Organization
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Legal Business Name | PREMIER FOOT AND ANKLE OF ILLINOIS, PC
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Dates
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Enumeration Date | 06/30/2014
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Last Update Date | 11/18/2016
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Provider Practice Location Address
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Address Line | 6810 STATE ROUTE 162 SUITE 20
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City | MARYVILLE
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State | IL
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Zip | 62062-8587
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Country | US
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Telephone | 618-288-2835
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Fax | 618-288-6162
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Provider Business Mailing Address
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Address Line | 6810 STATE ROUTE 162 SUITE 20
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City | MARYVILLE
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State | IL
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Zip | 62062-8587
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Country | US
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Telephone | 618-288-2835
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Fax | 618-288-6162
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Authorized Official
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Title or Position | OWNER/PODIATRIST
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Name | DR. GABRIEL CARDENAS JR.
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Credential | DPM
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Telephone | 618-288-2835
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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 | 016.005608
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License Number State | IL
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