Basic Information
Provider Information | |||||||||
NPI: | 1427069665 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FOOT & ANKLE CENTER, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | FOOT & ANKLE CENTER-GRANITE CITY | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1299 REAVIS BARRACKS RD | ||||||||
Address2: |   | ||||||||
City: | SAINT LOUIS | ||||||||
State: | MO | ||||||||
PostalCode: | 631253260 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3144879300 | ||||||||
FaxNumber: | 3144879338 | ||||||||
Practice Location | |||||||||
Address1: | 2013 A JOHNSON ROAD | ||||||||
Address2: |   | ||||||||
City: | GRANITE CITY | ||||||||
State: | IL | ||||||||
PostalCode: | 62040 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6184517475 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/11/2006 | ||||||||
LastUpdateDate: | 11/10/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | AQUINO | ||||||||
AuthorizedOfficialFirstName: | LOUIS | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 3144879300 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | FOOT & ANKLE CENTER, LLC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | DPM, FACAS | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | 016005263 | IL | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
No ID Information.