Provider Demographics
NPI:1104981422
Name:AFFILIATED PODIATRISTS OF ILLINOIS LTD.
Entity type:Organization
Organization Name:AFFILIATED PODIATRISTS OF ILLINOIS LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:W
Authorized Official - Last Name:GREENSPAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:847-562-9864
Mailing Address - Street 1:PO BOX 220
Mailing Address - Street 2:
Mailing Address - City:MATTESON
Mailing Address - State:IL
Mailing Address - Zip Code:60443-0220
Mailing Address - Country:US
Mailing Address - Phone:708-747-5850
Mailing Address - Fax:708-747-9991
Practice Address - Street 1:350 OAK KNOLL TER
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-1048
Practice Address - Country:US
Practice Address - Phone:847-562-9864
Practice Address - Fax:847-562-9865
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2009-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016-003364213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0002215448OtherBLUE SHIELD
IL016003364Medicaid
IL0002215448OtherBLUE SHIELD
ILT37845Medicare UPIN
ILK10254Medicare PIN
IL209983Medicare PIN
IL209979Medicare PIN
IL=========OtherTAX ID
IL480023483Medicare PIN
IL0002215448OtherBLUE SHIELD
ILK10256Medicare PIN
IL209978Medicare PIN