MEDICARE: EDGEBROOK FOOT & ANKLE CLINIC, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213ES0103X	Foot & Ankle Surgery Podiatrist	016.005386	IL

General Provider Information

NPI Number	:	1306071972
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EDGEBROOK FOOT & ANKLE CLINIC, INC

Provider Business Mailing Address
First Line	:	5330 W DEVON AVE
Second Line	:	SUITE 10
City	:	CHICAGO
State	:	IL
Zip	:	60646-4148
Country	:	US
Telephone Number	:	773-792-9300
Fax Number	:	773-792-9302

Provider Business Practice Location Address
First Line	:	5330 W DEVON AVE
Second Line	:	SUITE 10
City	:	CHICAGO
State	:	IL
Zip	:	60646-4148
Country	:	US
Telephone Number	:	773-792-9300
Fax Number	:	773-792-9302

Authorized Official
Title or Position	:	ADMINSTRATOR
Name	:	DR. PRATIBHA B PATEL
Credential	:	DPM
Telephone Number	:	773-792-9300

Provider Enumeration Date	:	05/26/2009
Last Update Date	:	06/08/2012

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