MEDICARE: MIDWEST FOOT & ANKLE SURGICAL CENTER

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	261QA1903X	Ambulatory Surgical Clinic/Center

General Provider Information

NPI Number	:	1730586561
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIDWEST FOOT & ANKLE SURGICAL CENTER

Provider Business Mailing Address
First Line	:	7940 FARMHOUSE RD
Second Line	:
City	:	FRANKFORT
State	:	IL
Zip	:	60423-6810
Country	:	US
Telephone Number	:	866-335-1091
Fax Number	:	866-335-1091

Provider Business Practice Location Address
First Line	:	3915 W CAPITOL DR
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53216-2528
Country	:	US
Telephone Number	:	866-335-1091
Fax Number	:	866-335-1091

Authorized Official
Title or Position	:	MEMBER
Name	:	DR. JEROME R RANDALL JR.
Credential	:	DPM
Telephone Number	:	866-335-1091

Provider Enumeration Date	:	11/21/2014
Last Update Date	:	11/21/2014

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