Basic Information
| Provider Information | |||||||||
| NPI: | 1043386469 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FOOT AND ANKLE WELLNESS CENTER AT SEVEN BRIDGES PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3540 SEVEN BRIDGES DR | ||||||||
| Address2: | SUITE 290 | ||||||||
| City: | WOODRIDGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605171221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6308528522 | ||||||||
| FaxNumber: | 6305412214 | ||||||||
| Practice Location | |||||||||
| Address1: | 3540 SEVEN BRIDGES DR | ||||||||
| Address2: | SUITE 290 | ||||||||
| City: | WOODRIDGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605171221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6308528522 | ||||||||
| FaxNumber: | 6305412214 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2006 | ||||||||
| LastUpdateDate: | 03/17/2021 | ||||||||
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| AuthorizedOfficialLastName: | VEKKOS | ||||||||
| AuthorizedOfficialFirstName: | LEONARD | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6308528522 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DPM | ||||||||
| NPICertificationDate: | 03/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | 016-003413 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 016003413 | 05 | IL | MEDICAID |