MEDICARE: WOODSTOCK MEDICAL & SURGICAL CENTER, LTD

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	261QP1100X	Podiatric Clinic/Center

General Provider Information

NPI Number	:	1801098314
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WOODSTOCK MEDICAL & SURGICAL CENTER, LTD

Provider Business Mailing Address
First Line	:	PO BOX 683
Second Line	:
City	:	WOODSTOCK
State	:	IL
Zip	:	60098-0683
Country	:	US
Telephone Number	:	815-334-8100
Fax Number	:	815-338-7105

Provider Business Practice Location Address
First Line	:	1666 S EASTWOOD DR
Second Line	:
City	:	WOODSTOCK
State	:	IL
Zip	:	60098-4655
Country	:	US
Telephone Number	:	815-334-8100
Fax Number	:	815-338-7105

Authorized Official
Title or Position	:	OWNER
Name	:	DR. KEVIN SEAN GAVIN
Credential	:	D.P.M.
Telephone Number	:	18474581800

Provider Enumeration Date	:	06/05/2007
Last Update Date	:	08/22/2020

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