Provider Demographics
NPI:1063691681
Name:DEGROOT FOOT & ANKLE CLINIC, PC
Entity type:Organization
Organization Name:DEGROOT FOOT & ANKLE CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:D
Authorized Official - Last Name:DEGROOT
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:815-462-9225
Mailing Address - Street 1:1938 E LINCOLN HWY
Mailing Address - Street 2:SUITE 206
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-3810
Mailing Address - Country:US
Mailing Address - Phone:815-462-9225
Mailing Address - Fax:815-462-5385
Practice Address - Street 1:1938 E LINCOLN HWY
Practice Address - Street 2:SUITE 206
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-3810
Practice Address - Country:US
Practice Address - Phone:815-462-9225
Practice Address - Fax:815-462-5385
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-31
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016005141213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0009932678OtherBLUE CROSS BLUE SHIELD
IL0009932678OtherBLUE CROSS BLUE SHIELD
IL216296Medicare PIN