Provider Demographics
NPI:1063535656
Name:SIEBERT PODIATRY PC
Entity type:Organization
Organization Name:SIEBERT PODIATRY PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:J
Authorized Official - Last Name:SIEBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-523-4539
Mailing Address - Street 1:102 S GRAND AVE W
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-3806
Mailing Address - Country:US
Mailing Address - Phone:217-523-4539
Mailing Address - Fax:
Practice Address - Street 1:102 S GRAND AVE W
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-3806
Practice Address - Country:US
Practice Address - Phone:217-523-4539
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL060.001013213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL60115587OtherBCBS
IL0802720001Medicare NSC
IL212945Medicare PIN
IL212946Medicare ID - Type UnspecifiedPROVIDER NUMBER SATELITE