Provider Demographics
NPI:1306071972
Name:EDGEBROOK FOOT & ANKLE CLINIC, INC
Entity type:Organization
Organization Name:EDGEBROOK FOOT & ANKLE CLINIC, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINSTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PRATIBHA
Authorized Official - Middle Name:B
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:773-792-9300
Mailing Address - Street 1:5330 W DEVON AVE
Mailing Address - Street 2:SUITE 10
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60646-4148
Mailing Address - Country:US
Mailing Address - Phone:773-792-9300
Mailing Address - Fax:773-792-9302
Practice Address - Street 1:5330 W DEVON AVE
Practice Address - Street 2:SUITE 10
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60646-4148
Practice Address - Country:US
Practice Address - Phone:773-792-9300
Practice Address - Fax:773-792-9302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-26
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016.005386213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty