Basic Information
| Provider Information | |||||||||
| NPI: | 1184614653 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FREEL | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1118 HAMPSHIRE ST | ||||||||
| Address2: | |||||||||
| City: | QUINCY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 623013027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172226550 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1118 HAMPSHIRE ST | ||||||||
| Address2: | |||||||||
| City: | QUINCY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 623013027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172226550 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2005 | ||||||||
| LastUpdateDate: | 11/09/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0131X | 000712 | MO | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot Surgery | 213ES0131X | 016-003720 | IL | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1184614653 | 05 | MO | MEDICAID | 00132005 | 01 | IL | BLUE CROSS/BLUE SHIELD | OTHER | 3074226001 | 01 | CIGNA | OTHER | 009464 | 01 | HEALTH ALLIANCE | OTHER | 127214 | 01 | HEALTHLINK | OTHER |