Basic Information
| Provider Information | |||||||||
| NPI: | 1588836134 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALPINE FOOT SPECIALIST PC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ALPINE FOOT SPECIALISTS PC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 765 ELA ROAD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | LAKE ZURICH | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600472339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475409949 | ||||||||
| FaxNumber: | 8475409971 | ||||||||
| Practice Location | |||||||||
| Address1: | 765 ELA ROAD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | LAKE ZURICH | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600472339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475409949 | ||||||||
| FaxNumber: | 8475409971 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2008 | ||||||||
| LastUpdateDate: | 06/24/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CHERRY | ||||||||
| AuthorizedOfficialFirstName: | DAWN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | BILLING | ||||||||
| AuthorizedOfficialTelephone: | 8475409949 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | 016003264 | IL | N | Suppliers | Durable Medical Equipment & Medical Supplies | 335E00000X | 016003264 | IL | Y | Suppliers | Prosthetic/Orthotic Supplier |
ID Information
| ID | Type | State | Issuer | Description | CL8623 | 01 | IL | RAILROAD MEDICARE | OTHER | 480003019 | 01 | IL | RAILROAD MEDICARE | OTHER |