=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740518307
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HMI FOOT AND ANKLE GROUP, SC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/19/2009
-----------------------------------------------------
Last Update Date | 11/11/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19255 EVERETT LN SUITE B
-----------------------------------------------------
City | MOKENA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60448-8958
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-656-3171
-----------------------------------------------------
Fax | 630-657-0131
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 711
-----------------------------------------------------
City | LOMBARD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60148-0711
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-656-3171
-----------------------------------------------------
Fax | 630-657-0131
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PODIATRIST
-----------------------------------------------------
Name | DR. HAYTHAM MANSOUR
-----------------------------------------------------
Credential | DPM, PHD
-----------------------------------------------------
Telephone | 630-656-3171
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | 016005301
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------