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General NPI Number Information
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NPI Number | 1700292711
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Entity Type | Organization
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Legal Business Name | ARCHER FOOT CLINIC
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Dates
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Enumeration Date | 07/10/2014
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Last Update Date | 07/10/2014
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Provider Practice Location Address
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Address Line | 3113 S ARCHER AVE
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City | CHICAGO
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State | IL
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Zip | 60608-6223
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Country | US
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Telephone | 773-284-9660
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Fax | 773-284-9676
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Provider Business Mailing Address
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Address Line | PO BOX 11232
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City | CHICAGO
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State | IL
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Zip | 60611-0232
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Country | US
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Telephone | 773-284-9660
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Fax | 773-284-9676
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Authorized Official
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Title or Position | ADMIN
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Name | AMIN MASHOUF
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Credential | MHA
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Telephone | 773-284-9660
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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 | 016005501
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License Number State | IL
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