Provider Demographics
NPI:1104899871
Name:ADVANCED FOOT & ANKLE CARE, LTD
Entity type:Organization
Organization Name:ADVANCED FOOT & ANKLE CARE, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARLA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:217-522-3622
Mailing Address - Street 1:1522 S 5TH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62703-2549
Mailing Address - Country:US
Mailing Address - Phone:217-522-3622
Mailing Address - Fax:217-522-3046
Practice Address - Street 1:1522 S 5TH ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703-2549
Practice Address - Country:US
Practice Address - Phone:217-522-3622
Practice Address - Fax:217-522-3046
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-10
Last Update Date:2011-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016-004880261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4482080001OtherDMEPOS
IL209975Medicare PIN
IL209973Medicare PIN