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General NPI Number Information
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NPI Number | 1902180201
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Entity Type | Organization
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Legal Business Name | FREEDOM FOOT CLINICS OF ILLINOIS SC
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Dates
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Enumeration Date | 10/05/2011
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Last Update Date | 10/05/2011
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Provider Practice Location Address
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Address Line | 3245 GROVE AVE SUITE #103
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City | BERWYN
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State | IL
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Zip | 60402-3474
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Country | US
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Telephone | 708-484-3599
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Fax | 708-749-0727
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Provider Business Mailing Address
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Address Line | 3245 GROVE AVE SUITE #103
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City | BERWYN
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State | IL
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Zip | 60402-3474
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Country | US
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Telephone | 708-484-3599
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Fax | 708-749-0727
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Authorized Official
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Title or Position | PODIATRIST
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Name | DR. CYNTHIA MERCADO I
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Credential | DPM
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Telephone | 708-484-3599
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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 | 016004482
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License Number State | IL
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