Basic Information
| Provider Information | |||||||||
| NPI: | 1073817805 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SUBURBAN PODIATRY ASSOCIATES, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 303 E ARMY TRAIL RD | ||||||||
| Address2: | SUITE #101 | ||||||||
| City: | BLOOMINGDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601082169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6308933668 | ||||||||
| FaxNumber: | 6308933670 | ||||||||
| Practice Location | |||||||||
| Address1: | 303 E ARMY TRAIL RD | ||||||||
| Address2: | SUITE #101 | ||||||||
| City: | BLOOMINGDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601082169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6308933668 | ||||||||
| FaxNumber: | 6308933670 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2011 | ||||||||
| LastUpdateDate: | 02/22/2012 | ||||||||
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| AuthorizedOfficialLastName: | JANSYN | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
| AuthorizedOfficialMiddleName: | MARTIN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6308933668 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.P.M. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | 016-003968 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
No ID Information.