=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811183502
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUBURBAN FOOT AND ANKLE SPECIALISTS P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/17/2007
-----------------------------------------------------
Last Update Date | 09/17/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 475 N FARNSWORTH AVE
-----------------------------------------------------
City | AURORA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60505-3004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-898-0022
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 444
-----------------------------------------------------
City | LAKE FOREST
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60045-0444
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | LEWIS WASSERMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 847-219-0539
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0131X
-----------------------------------------------------
Taxonomy Name | Foot Surgery Podiatrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------