Provider Demographics
NPI:1316117799
Name:FAMILY PODIATRY OF DEKALB INC
Entity type:Organization
Organization Name:FAMILY PODIATRY OF DEKALB INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NEIL
Authorized Official - Middle Name:B
Authorized Official - Last Name:LEVIN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:815-899-2575
Mailing Address - Street 1:1675 BETHANY RD
Mailing Address - Street 2:STE B
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-3124
Mailing Address - Country:US
Mailing Address - Phone:815-899-2575
Mailing Address - Fax:815-899-2581
Practice Address - Street 1:1675 BETHANY RD
Practice Address - Street 2:STE B
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-3124
Practice Address - Country:US
Practice Address - Phone:815-899-2575
Practice Address - Fax:815-899-2581
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-03
Last Update Date:2012-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016003556213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT34414Medicare UPIN
IL0782590001Medicare NSC
ILK19976Medicare PIN
IL212094Medicare PIN